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2024 Obesity Cecil Chapter

Obesity is a prevalent nutritional disorder in the United States, significantly impacting health-related expenses and associated with various health risks. It is classified by Body Mass Index (BMI) and can be influenced by genetic, environmental, and lifestyle factors. Treatment options include lifestyle changes, medications, and bariatric surgery, particularly for difficult cases.

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2024 Obesity Cecil Chapter

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1462 CHAPTER 201 Obesity

GENERAL REFERENCES
For the General References and other additional features, please visit Elsevier eBooks+ TABLE 201-1 CLASSIFICATION OF OVERWEIGHT AND
at https://ebooks.health.elsevier.com. OBESITY BY BODY MASS INDEX (BMI)
OBESITY CLASS BMI (kg/m2)
Underweight <18.5
Grade A References Normal 18.5-24.9
Overweight 25.0-29.9
A1. Garber AK, Cheng J, Accurso EC, et al. Short-term outcomes of the study of refeeding to optimize
inpatient gains for patients with anorexia nervosa: a multicenter randomized clinical trial. JAMA Obesity I 30.0-34.9
Pediatr. 2021;175:19-27.
A2. Golden NH, Cheng J, Kapphahn CJ, et al. Higher-calorie refeeding in anorexia nervosa: 1-year Obesity II 35.0-39.9
outcomes from a randomized controlled trial. Pediatrics. 2021;147:e2020037135. Extreme obesity III ≥40
A3. Hay PJ, Touyz S, Claudino AM, et al. Inpatient versus outpatient care, partial hospitalisation and
waiting list for people with eating disorders. Cochrane Database Syst Rev. 2019;1:CD010827. From Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the
A4. Monteleone AM, Pellegrino F, Croatto G, et al. Treatment of eating disorders: a systematic meta- management of overweight and obesity in adults: a report of the American College of Cardiology/
review of meta-analyses and network meta-analyses. Neurosci Biobehav Rev. 2022;142:104857. American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll
A5. Attia E, Steinglass JE, Walsh BT, et al. Olanzapine versus placebo in adult outpatients with anorexia Cardiol. 2014;63:2985-3023.
nervosa: a randomized clinical trial. Am J Psychiatry. 2019;176:449-456.
A6. Rosager EV, Møller C, Sjögren M. Treatment studies with cannabinoids in anorexia nervosa: a
systematic review. Eat Weight Disord. 2021;26:407-415.
A7. de Zwaan M, Herpertz S, Zipfel S, et al. Effect of internet-based guided self-help vs individual face- considerably at a BMI of more than 30, which is the definition of obesity. Obesity
to-face treatment on full or subsyndromal binge eating disorder in overweight or obese patients: is divided into three classes, also depending on BMI (see Table 201-1).
the INTERBED randomized clinical trial. JAMA Psychiatry. 2017;74:987-995.
A8. Hudson JI, McElroy SL, Ferreira-Cornwell MC, et al. Efficacy of lisdexamfetamine in adults Young adults, who accumulate greater exposure to metabolic and mechani-
with moderate to severe binge-eating disorder: a randomized clinical trial. JAMA Psychiatry. cal damage from being overweight or obese throughout their lives, are at
2017;74:903-910. increased risk for chronic health conditions such as coronary heart disease
A9. Feltner C, Peat C, Reddy S, et al. Screening for eating disorders in adolescents and adults: evidence
report and systematic review for the US Preventive Services Task Force. JAMA. 2022;327:1068-1082.
and type 2 diabetes mellitus. By comparison, the increase in mean BMI with
age, though deleterious, is not as much of a threat to population health as is
a similar increase in the BMI of younger populations.
The lowest mortality rates for young adults have historically been for a

201
BMI in the normal range (20.0 to 24.9), whereas the BMI associated with
the lowest mortality rates is somewhat above 25 kg/m2 for adults in their 60s
and 70s.7 Data also suggest that the optimal BMI may be about 27.0 for older
OBESITY adults given current life expectancy data.

MICHAEL D. JENSEN AND DANIEL H. BESSESEN PATHOBIOLOGY

Genetic and constitutional susceptibility to obesity are heavily influenced by
the environment. Studies of twins adopted into different families indicate that
within a given environment, a significant portion of the variation in weight is
Obesity is the most common nutritional disorder in the United States, and it genetic. However, the growing prevalence of obesity is related to changes in
directly or indirectly accounts for a significant portion of health-related expenses. environment, not human genetics.
Lifestyle change, antiobesity medications, and bariatric surgery are evidence-
based treatment options, but each requires training and time to implement. Genetic Aspects of Human Obesity
Variants in the fat mass and obesity-associated (FTO) gene, which are relatively
DEFINITION common (16% of adults are homozygous for the predisposing allele), account
Obesity, which is a degree of excess adiposity that can predispose to adverse for only a few percent of the differences in body weight. Large genome-wide
health consequences, is a disease of body weight regulation, much as diabetes is association studies have identified over 100 loci that associate with BMI,
a disease of glucose regulation.1 Body mass index (BMI), calculated as weight but together these genes account for less than 3% of the variance in BMI.
in kilograms divided by height squared in meters, is the most commonly used The majority of the genes associated with BMI are expressed in the central
screening tool to assess the health risks related to weight. nervous system, thereby suggesting effects on ingestive behavior. Genome-wide
association studies have also identified about 50 loci that are associated with
EPIDEMIOLOGY waist-to-hip ratio after adjusting for BMI, but these loci combined account
More than 1.9 billion adults worldwide are overweight, and over 650 million for only 1 to 2% of the variance in waist-to-hip ratio. Most of these genes are
are obese.2 Obesity causes an estimated 4.7 million deaths worldwide. In the preferentially expressed in adipose tissue, thereby implying that hereditary
United States, over 70% of adults are overweight, and the prevalence of obesity differences in body fat distribution are driven by genetic factors.
is about 42% in women and 44% in men.3 BMI rises between ages 20 and 60 Genetic obesity is seen in a variety of childhood-onset conditions, includ-
years and falls slightly thereafter.4 Severe obesity is inversely associated with ing autosomal dominant Prader-Willi (Chapter 214) and Albright hereditary
urbanization,5 with a significantly greater prevalence of obesity and severe osteodystrophy, as well as autosomal recessive Laurence-Moon-Biedl, Cohen,
obesity among adults living in nonmetropolitan areas compared with large Carpenter, Alstrom, and Tubby syndromes. Virtually all monogenic obesity
metropolitan statistical areas.6 Black American women and Mexican Americans syndromes cause hyperphagia by disrupting parts of appetite regulation pathways.
of both sexes have the highest rates of overweight and obesity in the United For example, children with homozygous or compound heterozygous loss-of-
States. Women in lower socioeconomic classes are much more likely than those function mutations in the genes encoding leptin (LEP) and the leptin receptor
in higher socioeconomic classes to be obese, an association that reduces, but (LEPR) develop intense hyperphagia that results in severe obesity. Congenital
does not eliminate, the racial differences in the prevalence of obesity. Whether leptin deficiency results in undetectable serum leptin concentrations, whereas
the remaining racial differences in the prevalence of obesity are due to genetic, leptin concentrations are not unusually increased in those with LEPR deficiency.
constitutional, or social and environmental factors is not yet known. Approximately 5% of patients with severe, early-onset obesity have been reported
The health risks associated with increased adiposity increase continuously as BMI to have heterozygous loss-of-function MC4R mutations, which appear to be
exceeds 25 (Table 201-1). Lower BMI values of 23 to 24 are recommended for inherited in a codominant manner. The features of MC4R deficiency include
Asian populations, who are at risk for the typical metabolic complications of obesity hyperphagia, hyperinsulinemia, and increased linear growth. Homozygous or
at lower BMI and waist circumferences than are individuals of other ethnicities. compound heterozygous mutations in proopiomelanocortin (POMC) can result
Risks associated with being overweight are modest but are higher in the presence in hyperphagia and early-onset obesity, isolated adrenocorticotropic hormone
of central obesity. Some persons who are overweight (BMI of 25.0 to 29.9) may (ACTH) deficiency (due to lack of adrenocorticotrophin), and hypopigmenta-
have increased muscle mass rather than increased body fat; these individuals are tion of skin and hair (due to lack of signaling through the melanocortin 1 recep-
not difficult to identify clinically and do not have an elevated waist circumference. tor). Humans lacking prohormone convertase 1 also develop severe, early-onset
The prevalence of comorbid conditions and risk of new morbid conditions increase obesity and ACTH deficiency due to impaired processing of POMC.

Constitutional Influences on Obesity Energy Intake

Signals can affect hunger, which is the compelling need or desire for food;
Environmental factors can result in long-term, epigenetic effects that affect
satiation, which is the state of being satisfactorily full and unable to consume
body weight regulation and the susceptibility to obesity-related health prob-
more; and satiety, which is the sense of no longer being hungry. The hypo-
lems. For example, undernutrition in the last trimester of pregnancy and in
thalamus is a key component of the regulation of the intake of food (E-Fig.
the early postnatal period decreases the risk of adult obesity, although the low
201-1). Hypothalamic arcuate nucleus neurons synthesize neuropeptide Y
birthweight associated with undernutrition (or smoking) in late pregnancy
(NPY) and agouti-related protein (AgRP) and are activated under energy-
also increases the risk of adulthood hypertension, abnormal glucose tolerance,
deficit conditions by reduced levels of insulin and leptin, thereby resulting
and cardiovascular disease. In contrast, undernutrition limited to the first two
in the drive to eat (orexigenic response). When energy intake is sufficient,
trimesters of pregnancy is associated with an increased probability of adult
POMC neurons in the arcuate nucleus generate responses that reduce appe-
obesity. Infants of diabetic mothers tend to be fatter than those of nondia-
tite (anorectic responses). The neurons that express POMC also express
betic mothers, and children of diabetic mothers have a greater prevalence of
cocaine- and amphetamine-related transcript (CART). POMC is processed
obesity when they are 5 to 19 years old, independent of whether their mother
to the melanocortin (MSH) peptides alpha, beta, and gamma MSH, which
is obese. Finally, intrauterine exposure to the diabetic environment results in
are melanocortin 3 and 4 receptor (MC4R) agonists. These arcuate nucleus
an increased risk of diabetes mellitus and obesity in the offspring.
neurons project to MC4R-expressing neurons in the paraventricular nucleus,
Environmental Contributors to Obesity where activation of MC4R generates the anorectic response. In conditions
of energy deficit, the MC4R receptor is inhibited by AgRP. Neurons in the
Dramatic changes in the environment of developed and even developing countries
paraventricular nucleus also express NPY receptors, which, when activated,
over the past 50 years include reduced demands for physical activity and altera-
cause hunger. The balance among these numerous signals plays an important
tions in the food supply (Table 201-2). These changes in the food supply help
role in the desire to eat. Perhaps the most obvious example of how this pathway
explain why the reduced energy expenditures by persons in the industrial and
can be disrupted is the increase in hunger in response to high-dose, exogenous
postindustrial eras have not been accompanied by a decrease in energy intake.
corticosteroids; suppression of POMC neurons by corticosteroids results in
Food unopposed activity of NPY on paraventricular nucleus neurons.
The consumption of energy-dense foods results in greater energy intake because Satiety, which is the sense of no longer being hungry, is a complex set of post-
adults tend to respond to food volume rather than to the energy content. Many prandial events that affect the interval to and/or the amount consumed at the
high-fat foods are also energy dense and contribute to weight gain. The con- next meal. The leptin receptor is highly expressed in the hypothalamus. When it
sumption of sugar-sweetened beverages, such as soft drinks and fruit juices, is is activated by leptin, which is secreted by adipocytes, the expression of POMC
not accompanied by a decrease in food intake to offset the extra energy intake increases, thereby leading to reduced food intake. Gut peptides that can influence
and promotes weight gain. The larger portion size of food and beverages also food intake are secreted in response to mechanical stimuli (e.g., the fullness of
increases food intake. Food variety can also affect energy intake, and the ready the stomach) and/or the presence of nutrients in the jejunum and ileum. These
availability of an increased variety of entrees, sweets, snacks, and carbohydrates peptides include peptide YY 36 (PYY), glucagon-like peptide 1 (GLP-1), and
is associated with an increase in food intake and body fatness. In contrast, an oxyntomodulin (OXM) that, like leptin and insulin, inhibit neurons that express
increase in the variety of vegetables available does not appear to increase energy NPY and AgRP. In contrast, ghrelin activates NPY and AgRP neurons, thereby
intake and is not associated with increased body fatness. Other factors include generating a sensation of hunger, an effect that is exacerbated by prolonged fasting,
the reduced costs of food, increased availability, and palatability. Psychological possibly because leptin secretion decreases out of proportion to the loss of body fat.
factors such as dietary restraint or disinhibition, as well as the social context in In addition to the hypothalamic energy balance system, other central nervous
which the food is present, can influence how food properties affect energy intake. system responses have important effects on food intake (E-Table 201-1). Relevant
structures include the ventral striatum, where the reward aspects of food intake are
Physical Activity determined; the prefrontal cortex, where executive function and impulse control
Physical activity (Chapter 14) levels have been decreasing in the United take place; the brain stem, where vagal inputs from the gastrointestinal tract modu-
States and worldwide, as reduced activity at work is not replaced, on average, late food intake; and the cortex, where the social meaning of eating is interpreted.
by increased leisure activity. The result is decreased energy expenditure, Other factors that have been shown to affect food intake include cholecystokinin,
estimated to be over 100 calories/day, at a time when the food supply which causes satiation but has no effect on satiety, and pancreas-derived amylin,
has led to sustained or increased caloric consumption. The amount of which acts on the gastrointestinal tract and the hypothalamus to inhibit appetite.
time spent in sedentary pursuits is associated with an increased risk of Signals of energy availability from the small intestine, stomach, pancreas,
overweight and obesity, likely independent of participation in traditional and adipose tissue are relayed to the hypothalamus via the circulation. In the
exercise activities. arcuate nucleus of the hypothalamus, neurons that express NPY and AgRP
are activated under energy deficit conditions and drive feeding (orexigenic)
Regulation of Body Weight and Energy Balance responses by signaling to NPY1 receptor (Y1r) neurons in the paraventricular
The typical U.S. adult will take in and expend approximately 2000 to 3000 kcal/ nucleus (PVN). Ghrelin activates NPY and AgRP neurons, whereas PYY, GLP-1,
day. Consistent errors of even 1% in excess food consumption can result in OXM, insulin, and leptin inhibit these neurons. In the arcuate nucleus of the
body fat gain of 25 to 30 pounds in 10 years, assuming no change in energy hypothalamus, neurons that express POMC generate anorectic signals under
expenditure, so adults who do not gain weight must regulate their average energy conditions of energy surplus. POMC neurons coexpress CART. Anorectic pep-
balance with greater than 1% precision. This balanced regulation of energy intake tides (PYY, GLP-1, and OXM) activate POMC neurons. In the paraventricular
and energy expenditure requires both conscious and unconscious processes. nucleus, melanocortin melanocyte-stimulating hormone (α-MSH), which is a
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Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
CHAPTER 201 Obesity 1463.e1

Paraventricular
nucleus PVN Energy E-TABLE 201-1 CENTRAL NERVOUS SYSTEM REGULATION
neurons Balance OF APPETITE
Y1r
MC4R Brain region Functions Neurotransmitters
Hypothalamus Energy homeostasis Norepinephrine, GABA,
POMC, CART, AgRP, NPY
Ventral striatum Reward aspects of food Dopamine
Food intake
intake
Arcuate
Prefrontal cortex Executive function, Norepinephrine, dopamine,
nucleus Y2r impulse control glutamate
Brainstem, vagus nerve Signals from GI tract GLP-1
Food intake AgRP/NPY Cortex Social meaning of
eating
–
POMC/ AgRP = agouti-related protein; CART = cocaine- and amphetamine-related transcript; GABA =
CART γ-aminobutyric acid; GI = gastrointestinal; GLP-1 = glucagon-like peptide 1; NPY = neuropeptide Y;
POMC = proopiomelanocortin.

+ –
+

PYY3-36 Peripheral
signals
GLP-1, OXM Ghrelin
Leptin
Insulin

E -FIGURE 201-1. Central appetite regulation pathways. AgRP = agouti-related

protein; CART = cocaine- and amphetamine-related transcript; GLP-1 = glucagon-like
peptide 1; MC4R = melanocortin 4 receptor; NPY = neuropeptide Y; OXM = oxyntomodu-
lin; POMC = proopiomelanocortin; PVN = paraventricular nucleus; PYY3-36 = peptide
tyrosine tyrosine 3-36.

Dyslipidemia
Physical Activity Energy Expenditure Upper body obesity and type 2 diabetes mellitus are associated with increased concen-
The energy expenditure of physical activity is a product of the amount of trations of triglycerides, decreased concentrations of high-density lipoprotein (HDL)
work done and the work efficiency of the individual. Work units are expressed cholesterol, and a high proportion of small, low-density lipoprotein (LDL) particles
as metabolic equivalents (METs; see Table 14-1), a multiple of the RMR. (Chapter 190). This dyslipidemia contributes to the increased cardiovascular risk
If an individual’s RMR is 1 kcal/minute (1440 kcal/day), a workload of 5 observed in metabolic syndrome. Fasting hypertriglyceridemia is caused by increased
METs would be 5 kcal/minute. Although most sedentary individuals can hepatic very low density lipoprotein (VLDL) secretion, which may be driven by
work for only a limited amount of time at relatively low workloads, highly increased delivery of free fatty acids to the liver from both visceral fat and upper body
trained athletes can work at extremely high METs (>16) for extended periods. subcutaneous fat. The reduced HDL cholesterol concentrations and the increased
Nonexercise activity thermogenesis is the energy expense of performing all activities small, dense LDL particle concentrations associated with upper body obesity are
other than exercise- or employment-related activity. Such activities may include tasks likely an indirect consequence of elevated triglyceride-rich VLDL. Genetic influences
as mundane as getting up to walk 50 feet to the water fountain or spending 8 hours play a significant role in the expression of these lipid abnormalities. Polymorphisms
cleaning one’s living space. The range of observed nonexercise activity thermogenesis in the genes for apolipoprotein E, lipoprotein lipase, apolipoprotein B-100, and
varies from less than 100 to more than 800 kcal/day. On average, about 10% of the apolipoprotein A-II are correlated with increased triglycerides and decreased HDL.
energy content of food (ranging from a low of about 3% to a high of about 15%) is
expended in the process of digestion, absorption, and metabolism of nutrients. The Endocrine Manifestations of Obesity
energy expended from a physically demanding job or volitional exercise may or may Obesity is associated with abnormalities of the endocrine system, including poly-
not be offset by reductions in spontaneous (nonemployment) activity. cystic ovary syndrome (Chapter 218), which is characterized by mild hirsutism
and irregular menses or amenorrhea with anovulatory cycles. The insulin resist-
Secondary Causes of Obesity ance associated with obesity may trigger the development of polycystic ovary
A number of medications cause weight gain in some or most of the patients syndrome in susceptible individuals. Obese men may suffer from mild to severe
for whom they are prescribed (Table 201-3). Awareness of the medications hypothalamic hypogonadism (Chapter 216), which improves with weight loss.
that have this potential can facilitate weight loss treatment in some patients.
Less than 1% of obese patients have an underlying systemic disease that Systemic Complications of Obesity
can explain the development of their obesity. Endocrinopathies, which are the The excess body weight associated with obesity is thought to be responsible for
most common secondary cause of obesity, include Cushing syndrome (Chapter the increased prevalence of lower extremity degenerative joint disease (Chapter
208), hypothalamic damage that results in overeating (most commonly after 241). Severely obese individuals may also have problems with venous stasis
pituitary surgery), insulinoma (Chapter 211), and hypothyroidism (Chapter (Chapter 68), which is occasionally aggravated by right-sided heart failure.
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CHAPTER 201 Obesity 1465

TABLE 201-3 PHARMACOLOGIC INFLUENCES ON WEIGHT GAIN AND ALTERNATIVE THERAPIES

DRUGS THAT MAY PROMOTE WEIGHT GAIN ALTERNATIVE TREATMENTS: WEIGHT NEUTRAL OR WEIGHT LOSS
PSYCHIATRIC AND NEUROLOGIC MEDICATIONS ALTERNATIVE PSYCHIATRIC AND NEUROLOGIC MEDICATIONS
Antipsychotics: olanzapine, clozapine, risperidone, quetiapine, aripiprazole Ziprasidone
Antidepressants Nortriptyline, bupropion, nefazodone, fluvoxamine, sertraline, duloxetine
Tricyclics: imipramine, amitriptyline Topiramate, zonisamide (weight loss), lamotrigine (less weight gain)
Triazolopyridines: trazodone
Serotonin reuptake inhibitors: paroxetine, fluoxetine, citalopram
Tetracyclics: mirtazapine
Monoamine oxidase inhibitors
Antiepileptic drugs: gabapentin (higher doses), valproic acid, carbamazepine, divalproex
Mood stabilizers: lithium, carbamazepine, lamotrigine, gabapentin (higher doses)
STEROID HORMONES ALTERNATIVES TO STEROID HORMONES
Progestational steroids Barrier methods, intrauterine device
Corticosteroids Nonsteroidal anti-inflammatory drugs
Hormonal contraceptives
ANTIDIABETES AGENTS ALTERNATIVE ANTIDIABETES AGENTS
Insulin (most forms) Metformin
Sulfonylureas Acarbose, miglitol
Thiazolidinediones Exenatide
Dipeptidyl peptidase 4 inhibitors
Liraglutide
Sodium-glucose cotransporter 2 inhibitors
ANTIHISTAMINES ALTERNATIVES TO ANTIHISTAMINES
Commonly reported with older agents; also oxatomide, loratadine, and azelastine Decongestants, mast cell stabilizers, antagonists of endogenous mediators of
inflammation
ANTIHYPERTENSIVE AGENTS ALTERNATIVE ANTIHYPERTENSIVE AGENTS
α-Adrenergic and β-adrenergic receptor blockers Angiotensin-converting enzyme inhibitors
Calcium channel blockers: nisoldipine Angiotensin receptor blockers
Calcium channel blockers: most other agents
Diuretics
HIGHLY ACTIVE ANTIRETROVIRAL THERAPY

Sleep apnea (Chapter 374) is common in severely obese patients and is more Routine blood testing for persons with a BMI 25 to 35 kg/m2 and an ele-
prevalent in men and in women with an upper body/visceral obesity. Sleep apnea vated waist circumference should include a fasting glucose concentration and
is most likely explained by enlargement of upper airway soft tissue, resulting in a lipid panel. Other laboratory tests (thyroid and liver function studies) may
collapse of the upper airways during inspiration while sleeping. The obstruction be indicated if symptoms or signs warrant.
leads to apneas, with hypoxemia, hypercarbia, and high levels of catecholamines
and endothelins. The frequent arousals to restore breathing result in poor sleep TREATMENT
quality. Sleep apnea is associated with an increased risk of hypertension, and if
General Considerations
sleep apnea is severe, it can lead to right-sided heart failure and sudden death. Before a patient enters a weight management program, the clinician should try
Obesity is associated with an increased risk of at least 13 different types of to ensure that the patient is interested and ready to make lifestyle changes and
cancer (breast, esophageal, liver, gallbladder, stomach, pancreas, colorectal, ovarian, has realistic goals and expectations. Patients who expect to lose large amounts
uterine, renal cell, thyroid, meningioma, and multiple myeloma),9 likely due to of weight in a short time are virtually doomed to disappointment. Medical treat-
higher levels of insulin-like growth factor and estrogens. Obese individuals have ment programs, even if they include pharmacotherapy, struggle to achieve a
a greater prevalence of gastroesophageal reflux disease (Chapter 124) and gall- sustained weight loss of more than 10%. Although this amount of weight loss
stones (Chapter 141). Fatty liver and nonalcoholic steatohepatitis (Chapter 138) is sufficient to reduce the medical complications of obesity markedly, disap-
pointment with “only” 10% weight loss may cause patients to abandon a medi-
are strongly associated with overweight, obesity, and the metabolic syndrome. cally successful program. Helping the patient to accept that lifestyle changes
resulting in achievable (10%) weight loss is a reasonable, initial goal can be
challenging for a physician.
DIAGNOSIS It is sometimes necessary to delay entry into any treatment program if a
Evaluation of Obesity patient is not ready to make lifestyle changes. Every form of treatment currently
In the office practice, obtaining height and weight allows calculation of BMI. available requires some degree of lifestyle accommodation, and patients who
(https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm). are uninterested in doing so should be advised to reconsider their goals at a
later date. A reasonable strategy is to remind the patient of the health benefits
A review of the patient’s lifestyle, including an assessment of physical activity level of improved activity and eating habits at each visit and to reconsider efforts
(Chapter 14) and eating habits (Chapter 13), may help provide information about once a willingness to make changes is apparent.
why the patient is obese. A family history of obesity, or long-standing obesity, Treatment approaches may differ for individuals who are overweight and for
provides evidence against a secondary cause of obesity. A careful medication different classes of obesity. Simply making a diagnosis of obesity is associated
history, including over-the-counter medications, and social history may help with patients taking action to lose weight.10
the clinician identify precipitating factors that can be modified. Lifestyle treatment is appropriate for individuals who are overweight or
For patients with a BMI above 25 and below 35, measuring waist circumfer- obese, and pharmacotherapy can be an adjunct treatment for any class of
obesity, even if medical complications are not present, and may be considered in
ence is recommended to help with the treatment decision-making process. In patients who have a BMI above 27 plus a weight-related comorbid condition.10b
persons of European and African descent, waist circumference cut points of more Patients with class II obesity (BMI of 35.0 to 39.9) may be considered for bar-
than 102 cm (40 inches) for men and more than 88 cm (35 inches) for women iatric surgery if medical treatments have failed and if serious, weight-related
are indicators of increased metabolic risk. Adults with waist circumferences comorbid conditions are present. Class III obesity (BMI > 40) is one feature that
above the cut points deserve further evaluation to detect other cardiovascular might prompt consideration of a patient for bariatric surgery when medical
disease risk factors. Adults with class II or class III obesity are at sufficiently high treatments have failed.
risk that waist circumference information does not add valuable information. Obesity is a chronic disease, so its treatment (Fig. 201-1) must be considered
a long-term issue.10c Although severe dietary caloric restriction can result in
Blood pressure should be measured, with a large blood pressure cuff, if substantial weight loss, body fat is invariably regained without approaches
needed. A suspicion for sleep apnea should prompt a referral for an overnight to ensure behavioral changes. Patients must learn how to make permanent
sleep test (Chapter 374).

Assess and treat CVD risk Assess weight and lifestyle

factors and obesity-related histories
comorbidities
BMI 25-<30 (overweight)
Measure weight, or 30-<35 (class I obese)
Patient encounter height; calculate BMI or 35-<40 (class II obese) Yes BMI 25
or 40 (class III obese)
Assess need to lose weight:
BMI 30 or BMI 25-<30 with
No BMI 18.5-<25 No risk factor(s)
Insufficient risk
Measure weight and Advise to avoid weight gain;
calculate BMI annually address and treat other Yes
or more frequently risk factors
No
Not yet ready Assess readiness to
make lifestyle changes
to achieve weight loss
Follow-up and weight
loss maintenance
Yes, ready
High intensity
comprehensive lifestyle Determine weight loss and
intervention health goals and intervention
Yes Yes strategies
Alternative delivery of
lifestyle intervention

Intensive behavioral
treatment; reassess and Comprehensive lifestyle
address medical or other intervention alone or with
Weight loss 5% and contributory factors; Weight loss 5% and adjunctive therapies (BMI
sufficient improvement consider adding or sufficient improvement 30 or 27 with comorbidity)*
in health targets re-evaluating obesity in health targets
pharmacotherapy, and/or No
refer for to an experienced
No bariatric surgeon
BMI 40 or BMI 35 with
comorbidity. Offer referral
Continue intensive BMI 30 or BMI 27 with
to an experienced
medical management comorbidity—option for
bariatric surgeon for
of CVD risk factors adding pharmacotherapy as
consultation and
and obesity-related an adjunct to comprehensive
evaluation as an adjunct
conditions; weight lifestyle intervention*
to comprehensive
management options
lifestyle intervention

FIGURE 201-1. Flow diagram for the evaluation and management of overweight and obesity. BMI = body mass index; CVD = cardiovascular disease. *BMI cutpoint determined
by the U.S. Food and Drug Administration (FDA) and listed on the package inserts of FDA-approved obesity medications. (Modified from Jensen MD, Ryan DH, Apovian CM, et al. 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;63:2985-3023.)

Contrary to expectations, however, the opportunity to choose what diet to still feeling satisfied; leverage social/community support to begin and maintain
follow does not necessarily improve weight loss. More than 95% of patients behavior change; maintain perspective; and reduce all-or-nothing thinking as
embarking on self-diets or fad diets fail to maintain a significant weight loss for a way to maintain motivation and prevent relapse.
a time that would have meaningful health benefits. The best weight loss results are provided by in-person, high-intensity
Very low calorie diets (<800 calories per day) can achieve accelerated weight (≥14 sessions in 6 months) comprehensive behavioral interventions, which
loss under expert supervision. Because the long-term results of these diets are average an 8-kg (5 to 10% of body weight) loss in 6 months, even in under-
no better and sometimes worse than the results from the standard low-calorie served populations.A7 Approaches that provide electronically delivered coun-
diet combined with behavior modification, these diets are not commonly used. seling (telephone or Internet),A8,A9 including some commercial programs, can
Intermittent or alternate-day fasting and time-restricted eating are no better also achieve weight loss, but generally less than with in-person approaches.
than standard weight-loss dietsA4-A5b and are not advocated as primary strategies Commercial programs that have published their results in peer-reviewed jour-
because of inadequate evidence. nals are preferred. Physicians who refer patients to programs that offer intensive,
Commercial weight-loss programs (e.g., Weight Watchers, Jenny Craig, comprehensive lifestyle interventions are encouraged to obtain outcomes data
Nutrisystem) generally result in 2 to 4% more weight loss than usual education from those programs.
and counseling. The average weight loss is 4.8 to 6.6 kg at 6 months when con-
ventional foods are consumed and 6.6 to 10.1 kg at 12 months when prepared Pharmacotherapy
food is provided. Comprehensive weight management programs delivered at General Principles
academic medical centers that employ behavior modification, dietary instruc- Drugs to help patients lose weight should be used in concert with a compre-
tion, and physical activity can achieve equally or more impressive results. hensive lifestyle intervention by knowledgeable clinicians (Table 201-4).13-13e
Measurement of BMR is sometimes helpful for evaluating patients who insist Anti-obesity medications may be considered in patients who, despite lifestyle
that they are unable to lose weight despite following a diet that contains less interventions alone, have a BMI greater than 30 in the absence of a weight-
than 1000 kcal/day. Almost without fail, BMR measured with a reliable instru- related comorbidity or a BMI of 27 to 30 in the presence of a weight-related
ment is substantially greater than the reported food intake, thereby confirm- comorbidity. When discussing the possible prescription of anti-obesity medica-
ing that patients must be eating as much as, if not more, than their energy tions, key considerations include:
expenditure. This finding underscores the fact that most adults are unreliable 1. Anti-obesity medications vary in their effectiveness, side effects, and associ-
in assessing their own food intake. ated benefits.
2. Physicians should consider each patient’s comorbid conditions and prefer-
Physical Activity ences to tailor treatment for each individual.
A long-term increase in physical activity (Chapter 14), either through the activi- 3. Cost is commonly an important issue in deciding which medication a patient
ties of daily living or through regular exercise, is key to sustained, long-term will be able to use. Since newer medications are expensive and insurance
weight loss.A6 Although exercise (fitness- and sports-related activities) is a coverage remains limited, many people who are living with obesity and who
component of thermogenesis, most adults do not exercise at high levels or qualify for an anti-obesity medication will not be able to access these newer
for a sufficient duration to expend a large amount of energy, so focusing solely medications.
on “exercise” as the main component of physical activity will miss significant 4. The response to each anti-obesity medication varies widely from patient to
opportunities for improving energy balance. In addition, only about 100 kcal are patient. Average reported weight losses are known for each medication, but
expended by a 70-kg adult walking 1 mile. Losing weight solely by increasing some individuals may lose very little or no weight whereas others may lose
exercise is impractical for most patients. However, increasing physical activity substantial weight with any agent.
as a means of maintaining weight loss is an attainable goal for most patients. 5. A patient can try one anti-obesity medication for several months, see how
Successful maintenance of weight loss usually entails maintaining a daily effective it is and whether it causes any side effects, and then decide whether
energy expenditure approximately 80 to 90% above BMR, a considerable ongoing therapy is justified.
increase for most patients. For example, someone with a BMR of 1500 kcal/day 6. A 5% weight loss within 3 months is considered the minimally acceptable
would need to expend about 1000 kcal/day in physical activity to meet this response. If a patient loses less than this amount, the medication should be
target. Activities other than exercise (e.g., sports or fitness pursuits), includ- discontinued and an alternative medication should be considered.
ing lifestyle approaches such as habitually increasing the amount of walking 7. Anti-obesity medications are effective only for as long as they are taken.
throughout the day, are often important to reach this target. If a person loses weight while using an anti-obesity medication but then
Persuading obese patients to become more active is not easy. Physicians can stops taking the medication, the lost weight will likely be regained over a
begin by asking patients about their current and past activity habits as well as period of months. As a result, patients must be open to long-term use of
what barriers they see to increasing physical activity. If patients agree to begin an these medications.
exercise or physical activity program, they will need to set realistic goals for the
amount of exercise they are going to achieve and to monitor their activity. Unlike Choosing Among Currently Available Medications
highly fit individuals, obese sedentary adults often become so uncomfortable All of the anti-obesity medications that are approved by the U.S. Food and Drug
that they cannot continue exercising at what might be considered moderate Administration (FDA) for long-term use are better than placebo for achieving
levels of activity because their lactate threshold (the level of work that causes weight loss.A10 Most of these currently available medications reduce appetite
blood lactate concentrations to increase dramatically) is low. Even walking as (Table 201-4B). These appetite suppressants include agonists to the glucagon-
slow as 3 miles per hour may exceed the lactate threshold for adults who are like peptide 1 (GLP-1) receptor (semaglutide and liraglutide), a dual glucose-
obese with type 2 diabetes. The ready availability of step counters and electronic dependent insulinotropic polypeptide and GLP-1 receptor agonist (tirzepatide),
activity monitoring devices built into many “smartphones” offers a practical a sympathomimetic amine (phentermine) alone or with a g abaminergic agent
means for patients to track physical activity throughout the day and to assess (topiramate), and a pure opioid antagonist (naltrexone) combined with a weak
the effects of changes in lifestyle on their activity level. Many Americans take inhibitor of the reuptake of dopamine and norepinephrine (buproprion). By
as few as 4000 to 5000 steps per day, whereas it may take as many as 15,000 to comparison, orlistat causes fat malabsorption by inhibiting pancreatic lipase.
17,000 steps per day for patients who have lost significant amounts of weight to No reliable method can predict which patient will respond to which anti-obe-
maintain that lower weight. Gradually increasing the number of steps regularly sity medication. Each of the approved medications has advantages, side effects,
taken during the day through a series of changes in habits (e.g., parking farther and cost considerations, especially until the price of newer agents declines or
away, walking during work breaks) is more likely to result in long-term success insurance coverage expands. Physicians should consider their patients’ comor-
for most persons than setting aside 2 hours or more for continuous walking. bid conditions and preferences to tailor treatment for each individual. For
Gradual increases in physical activity also will improve fitness and eventually example, tirzepatide and semaglutide are the most effective agents that are
allow for sufficient energy expenditure to help maintain weight loss. currently approved by the FDA for the treatment of obesity in the absence of

Behavior Modification
Patients who are unable to make changes in eating activity habits on their own
or with informal office counseling may benefit from referral to an interven- TABLE 201-4 INDICATIONS FOR PHARMACOLOGIC
tionist or commercial program that provides weight-loss–specific behavioral TREATMENT OF OBESITY
therapy.12 The goals are to help patients modify their eating, activity, and think-
ing habits that predispose to obesity and focus on specific pathways to achieve Body mass index > 30 kg/m2 or BMI > 27 to 30 kg/m2 with one or more complications
the goals. As part of this process, patients are taught the benefits of and how or conditions that are likely to improve with weight loss
to self-monitor (food intake, activity, environmental cues); set goals (realistic Previous failure of conservative treatment with behavioral intervention, diet, and exercise
short-, medium-, and long-term goals that are specific, measurable, attainable, Agree to 2- to 4-wk trial of making initial changes in diet and exercise before starting
relevant, and time-limited); identify and leverage personal strengths to change pharmacotherapy
behavior; create a healthy external environment (stimulus control—identify and Agree to continue treatment with comprehensive lifestyle attempts while receiving
modify the environmental stimuli that thwart changes in eating/activity habits); support with pharmacologic treatment
manage stress if it causes extra eating or reduces planned activity; manage Agree to periodic follow-up
emotional triggers that may cause someone to eat so as to feel better); be more Premenopausal women (able to have children) must use some form of contraception
mindful about eating and enjoy food more, so as to limit the amount eaten while Consider a pregnancy test on initiation of treatment if there is any possibility of pregnancy
No contraindications to the specific drug used for pharmacologic treatment

1468
AVERAGE APPROXIMATE
PLACEBO- PROPORTION
DOSE AND SUBTRACTED OF PATIENTS
ROUTE OF % WEIGHT ACHIEVING 5% COST FOR
GENERIC ADMINISTRA- LOSS AT 12-24 WEIGHT LOSS AT 1-MONTH
NAME MECHANISM OF ACTION TION MONTHS* 12-24 MONTHS* SIDE EFFECTS CONTRAINDICATIONS SUPPLY† SPECIFIC INDICATIONS
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CHAPTER 201
Tirzepatide Dual agonist to glucagon-like 5 mg SQ once 11.9% to 17.8% 85 to 90% Common: nausea, vomiting, Family history of MEN type $1060 Patient with at least 10% weight
peptide 1 (GLP-1) and glucose- weekly, depending depending on constipation II syndrome; personal loss clinically indicated,
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.

dependent insulinotropic titrating up on dose dose Possible/rare: pancreatitis, history of medullary especially in the presence of
polypeptide (GIP) receptors; to 15 mg SQ gallbladder disease thyroid cancer diabetes
slows gastric emptying; central once weekly
effects on satiety as well
Semaglutide Glucagon-like peptide 1 2.4 mg SQ once 11.4% 80%* Common: nausea, vomiting, Family history of MEN type $1100 Patient with at least 10% weight

Obesity
(GLP-1) receptor agonist; weekly (or constipation II syndrome; personal loss clinically indicated,
slows gastric emptying and starting at 3 Possible/rare: pancreatitis, history of medullary especially in the presence of
acts centrally to increase mg PO daily if gallbladder disease thyroid cancer diabetes or cardiovascular
satiety diabetes)‡ disease; oral therapy is an option
in type 2 diabetic individuals
who prefer it to SQ injections
Liraglutide Glucagon-like peptide 1 (GLP-1) 3 mg daily SQ 4.7% 65%* Common: nausea, vomiting, Family history of MEN type $1090 Patient with type 2 diabetes
receptor agonist; slows gastric constipation II syndrome; personal whose insurance will not cover
emptying and acts centrally to Possible/rare: pancreatitis, history of medullary weekly injectables
increase satiety gallbladder disease thyroid cancer
Phentermine- Phentermine: as below; 7.5 mg/46 mg 7.9%* 75% Common: same as phentermine Same as phentermine plus $100-$150 Young or middle-aged patient
topiramate- topiramate: GABA-ergic PO once daily; plus paresthesias, dysgeusia, pregnancy category X with no risk of becoming
extended agent used for epilepsy, can increase to cognitive dysfunction (topiramate); consider pregnant and no history of
release (DEA carbonic anhydrase inhibitor 15 mg/92 mg Possible/rare: same as avoiding in patients with cardiovascular disease, but with
schedule IV) once daily phentermine plus glaucoma, glaucoma, nephrolithiasis history of migraine headache
nephrolithiasis§
Phentermine Sympathomimetic amine; 8 mg PO once 3-7%|| Unknown Common: dry mouth, Cardiovascular disease including $5-20 Young or middle-aged
(DEA increases norepinephrine daily; can insomnia, constipation, arrhythmia, history of patient with no history of
schedule (primarily), dopamine, and increase up to anxiety, headache substance use disorder, cardiovascular disease and
IV) serotonin in hypothalamic 37.5 mg PO Possible/rare: elevated blood hyperthyroidism, poorly for whom affordability of
nuclei that regulate hunger once daily pressure, tachyarrhythmia controlled hypertension, medications is a concern
Theoretical: cardiovascular valvular heart disease
events such as myocardial Limited to 3 months of use in
infarction, stroke many states
Naltrexone- Naltrexone: pure opioid 8 mg/90 mg PO 4.1% 65% Common: headache, Seizure disorder or high $30 as Patient with alcohol use disorder,
bupropion- antagonist. Bupropion: once daily, dizziness, nausea, vomiting, risk of seizures; opioid two pill tobacco use disorder, and/or
sustained weakly inhibits neuronal increasing to depression, initial increase in use; uncontrolled generic; depression but no history of
release reuptake of dopamine and 16 mg/180 mg blood pressure that resolves hypertension; hepatic $500 as hypertension who, if cost is a
norepinephrine. Mechanism twice daily by 12 weeks in randomized cirrhosis; current or recent single pill concern, would be willing to
leading to weight loss not controlled trials (<14 days) use of MAO brand take two separate pills
fully understood. Rare: seizure, cholecystitis, inhibitor, pregnancy name
suicidal ideation
Orlistat Reversible inhibitor of gastric 120 mg PO tid 3.2%* 50% Common: flatulence, oily Pregnancy, chronic $50-60 Patient for whom cost is an issue
and pancreatic lipases; with meals (60 stools, fecal urgency, fecal malabsorption syndrome (e.g., and who has low concern
inhibits absorption of mg tid with incontinence celiac disease, inflammatory about GI adverse effects or is
dietary fats meals OTC) Rare/theoretical: liver failure bowel disease, prior bariatric adhering to a very low-fat diet¶
surgery), cholestasis
*Data from randomized trials.
†
Wholesale price in U.S. dollars, not including any insurance coverage.
‡
Starting at 3 mg daily and potentially increasing to 7 mg daily on day 30 and 14 mg daily on day 60.
§
In clinical trials, there was no difference in serious adverse event rate for active drug participants compared to placebo.
||
Data from uncontrolled studies and observational cohort studies.
¶
It is recommended that a daily multivitamin be prescribed with orlistat due to malabsorption of fat-soluble vitamins.
DEA = U.S. Drug Enforcement Administration; GABA = gamma-aminobutyric acid; GI = gastrointestinal; MAO = monoamine oxidase; MEN = multiple endocrine neoplasia; OTC = over-the-counter; PO = orally; SQ = subcutaneously; tid = three times daily.
CHAPTER 201 Obesity 1469

diabetes, but they are given as self-injections and are expensive. However, about 4% greater weight loss than placebo, and this combination may be especially
20% of obese adults have type 2 diabetes, which is associated with overweight helpful in individuals with food cravings. This combination should not be used in
or obesity in about 85% of diabetic adults, and both tirzepatide and semaglu- individuals who have a seizure disorder or are using opioids. The cardiovascular
tide are covered by the U.S. Medicare program for the treatment of diabetes. In risk of this combination remains uncertain.A18
this setting, oral semaglutide also may be an attractive FDA-approved option Orlistat (120 mg three times daily with meals by prescription or 60 mg three
to subcutaneous semaglutide or tirzepatide. Phentermine monotherapy is the times daily over-the-counter) blocks fat absorption from the gastrointestinal
least expensive option, and the combination of phentermine/topiramate is tract. It provides only modest weight loss, has moderate gastrointestinal side
the most effective currently FDA-approved oral medication for obesity in the effects, can result in vitamin deficiency, and is now rarely indicated under expert
absence of diabetes. However, phentermine can have cognitive side effects, oversight.
and phentermine monotherapy (but not combined phentermine/topiramate Setmelanotide is a melanocortin-4 receptor agonist that is used for monogenic
therapy) is subject to limited prescribing periods in some states. Topiramate obesity syndromes under expert supervision. Examples include leptin receptor
can have benefits for people who have migraine headaches (Chapter 367) or deficiency, Bardet-Biedl syndrome, and proopiomelanocortin deficiency.
seizure disorders (Chapter 372). Bupropion might be useful in a person with
underlying depression (Chapter 362). Orlistat is the lowest risk option, but it Other Products
has gastrointestinal side effects that often are poorly tolerated. Gelesis100 (3 capsules, 2.25 g total dose with water before lunch or dinner) is a
non-systemic, superabsorbent hydrogel whose particles expand in the stomach
Glucagon-Like Peptide 1 Receptor Agonists and Related Agents after ingestion to create a sense of fullness. One capsule twice daily before meals
Glucagon-like peptide 1 (GLP-1) receptor agonists and related agents, which are produces about a 2% weight loss, but this drug is rarely used.
effective for the treatment of type 2 diabetes (Chapter 210), are also effective
for the treatment of obesity.14 Weight losses are usually somewhat less in type Experimental Medications
2 diabetic patients compared with nondiabetic individuals. Cagrilintide, an amylin analogue, is an investigational once-weekly subcutane-
Tirzepatide, which is the most potent FDA-approved weight loss medication ous drug that appears to be quite effectiveA19 and is being studied in combina-
(at 15 mg once weekly subcutaneously),A11 can produce about an 18% average tion with semaglutide. Orforglipron is an oral nonpeptide glucagon-like peptide
weight loss, and nearly 60% of individuals can lose more 20% of their body 1 (GLP-1) receptor agonist that can reduce weight by about 10%.A19b Retatrutide,
weight.A12-A13b Even individuals who have previously lost greater than 5% of their which is a subcutaneous triple agonist of the glucose-dependent insulinotropic
body weight with an intensive lifestyle intervention can achieve this impressive polypeptide (GIP), GLP-1, and glucagon receptors, has been associated with
incremental weight loss with tirzepatide.A13c Tirzepatide-induced weight loss can average weight losses of up to 24%.A19c
also significantly improve manifestations of moderate-to-severe sleep apnea.A13d Endoscopic Treatment of Obesity
Semaglutide subcutaneously (2.4 mg once weekly) subcutaneously can reduce Endoscopic approaches to treating obesity include space-occupying devices in
weight by about 12% in people who have obesity without diabetes,A14-A16 in whom the stomach (intragastric balloons),15 gastroesophageal stents that exert pres-
it also reduces the future development of type 2 diabetes.A16b The addition of sure on the gastric cardia to create a sensation of fullness, and gastric remodel-
intensive behavioral therapy to semaglutide alone may not substantially increase ing techniques that reduce the gastric reservoir by creating a tubular sleeve
weight loss, thereby suggesting that the role of lifestyle as a means to weight loss along the greater curvature of the stomach and aspiration therapy. Intragastric
may be limited in people who take this medication.A16c Semaglutide is associated balloons can result in significantly more weight loss than lifestyle modifications
with a 20% reduction in the risk of cardiovascular events A16d and a 22% reduction aloneA20 and are a potential option in patients who have a BMI over 30 and
in adverse renal events (significantly reduced glomerular filtration rate or persis- cannot use glucagon-like peptide 1 agonists. Endoscopic small bowel inter-
tent macroalbuminuria)A16e in non-diabetic individuals who are ages 45 years or ventions, such as excluding the proximal small intestine using impermeable
older and who have preexisting cardiovascular disease and a BMI of 27 kg/m2 polymer duodenojejunal bypass liners and ablative duodenal resurfacing tech-
or greater.A16d Semaglutide also improves symptoms and walking time in obese niques that regenerate the proximal small intestinal mucosal barrier in hopes of
patients who have heart failure with a preserved ejection fraction,A16f-A16h and it modifying ingestive behavior, are under investigation. Another approach is to
also reduces adverse outcomes in all patients who have heart failure regardless insert self-assembling magnets that create a dual-path enteral bypass between
of their left ventricular ejection fraction.A16i In patients who have diabetes as well the proximal jejunum or duodenum and the ileum, with the goal of diverting
as obesity, oral semaglutide (starting at 3 mg daily and potentially increasing to bile to the terminal ileum. Data currently are insufficient to guide when, if ever,
7 mg daily on day 30 and 14 mg on day 60, depending on the response) is as these endoscopic options should be recommended.
effective as subcutaneous semaglutide for weight loss.A16j Higher doses (50 mg
daily) produce more weight lossA16k but are not FDA-approved. Bariatric Surgery
Liraglutide (3 mg per day subcutaneously) also can reduce weight by an Bariatric surgery, which almost always results in more weight loss than lifestyle
average of about 8% more than lifestyle alone,A16l but it is less efficacious than or antiobesity medications, can be considered in patients who have a BMI of
tirzepatide or semaglutide.A17 However, liraglutide may become an attractive 35 to 40 plus serious weight-related comorbid conditions, especially uncon-
option when it becomes available as a less expensive generic drug by 2025. trolled type 2 diabetes, assuming prior attempts at medical treatments have
Tirzepatide, semaglutide, and liraglutide all generally share the same side failed,16,A21 or a BMI higher than 40. The benefits of bariatric surgery compared
effects. The principal side effect is nausea. They also can cause gastroparesis with medical treatment include long-term reduced risks of obesity-related
or bowel obstruction, and they increase the risk of pancreatitis and probably comorbidity; improvement or remission of type 2 diabetes, hypertension,
of gallbladder disease.14b They should be discontinued at least a week before and dyslipidemia; and a likely reduction in long-term mortality,A22–A24 includ-
any gastrointestinal endoscopy or surgical procedure. When these medications ing obesity-associated cancer and cancer-related mortality.17 However, these
are discontinued, most patients regain much of the weight they had lost.A17b benefits must be balanced against a small (<0.5%) risk of death, potential
surgical complications, and longer-term risks for nutritional deficiencies, new-
Other Anti-obesity Medications onset depression, treatment with opioids, and the need for additional surgical
Because many patients are not able to access and use newer, highly effective procedures.
anti-obesity medications, clinicians still should be prepared to discuss the risks Laparoscopic approaches are routinely used for bariatric surgery because
and benefits of older medications used to treat obesity. they reduce the length of hospitalization and the risk of incisional hernias com-
Phentermine (at doses ranging from 8 mg to 37.5 mg orally daily), which pared with open procedures. Contraindications to surgery include active sub-
is the most widely used alternative, provides a weight loss of 3 to 5% of body stance abuse, defined noncompliance or inability to comply with medical care,
weight. Phentermine should not be prescribed in individuals who have hyper- and schizophrenia, borderline personality disorder, or uncontrolled depression.
tension or known coronary artery disease, who are at high risk for cardiovascular A multidisciplinary team (including a physician, dietitian, psychologist or psy-
disease, or who have a history of substance abuse, anxiety, or bipolar illness. chiatrist, and experienced surgeon) is important for optimal outcome. Most suc-
Phentermine can increase the pulse and blood pressure, but data suggest a cessful patients will achieve weight losses of 25 to 35% of body weight but are not
low risk of cardiovascular complications when phentermine is used in appro- likely reach their ideal body weight. Follow-up to support the necessary changes
priately selected patients whose blood pressures and pulse rates are monitored, in long-term behavior is recommended to optimize weight loss outcomes.
including a follow-up visit 7 to 10 days after initiating or increasing the dose. Among the available bariatric surgical techniques, procedures that only
Although phentermine monotherapy is FDA-approved for only three months modify the capacity of the stomach (laparoscopic gastric banding) are much
of use, long-term prescribing is allowed in some U.S. states. less effective than Roux-en-Y gastric bypass in terms of long-term weight loss.
The combination of oral phentermine with oral extended-release topiramate Procedures that both reduce stomach size and modify other stomach prop-
(either 7.5 mg phentermine/46 mg extended-release topiramate or 15 mg/92 mg erties (e.g., sleeve gastrectomy) appear to be almost as effective as Roux-
daily), which can be used chronically in all U.S. states, produces about a 9% en-Y gastric bypass in terms of long-term weight loss and outright surgical
greater weight loss than placebo. Topiramate can cause birth defects, so women success, with durable benefits in terms of type 2 diabetes, hypertension, and
of childbearing age must use an effective form of birth control while using dyslipidemia.A25,A26 The partial pancreaticobiliary bypass, the very long limb
this medication. Topiramate also can cause constipation, sinusitis, dry mouth, Roux-en-Y gastric bypass, and the duodenal switch procedures create malab-
numbness and tingling in the fingers, and cognitive side effects, particularly sorption that results in greater weight loss than with the standard Roux-en-Y
at higher doses; these side effects may diminish with chronic use and typically gastric bypass. Unfortunately, the incidence of severe and even fatal vitamin
resolve with the discontinuation of the medication. and mineral deficiencies (Chapter 199) is much higher with these procedures.
The combination of oral naltrexone plus bupropion (starting at 8 mg/90 In patients who have a suboptimal response to bariatric surgery, adjuvant lira-
mg and increasing to 16 mg/180 mg twice daily) produces an average 3 to glutide (3 mg subcutaneously daily) is effective for promoting weight loss.A26b

Descargado para Yannko gonzalez (yannko2003@yahoo.es) en Valencian School of Health Studies de ClinicalKey.es por Elsevier en diciembre 11, 2024.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
1470 CHAPTER 201 Obesity
A7. Katzmarzyk PT, Martin CK, Newton RL Jr, et al. Weight loss in underserved patients: a cluster-
Surgical mortality and morbidity (e.g., infection, anastomotic leak, wound randomized trial. N Engl J Med. 2020;383:909-918.
dehiscence) are low in centers with expertise, despite the high-risk popula- A8. Baer HJ, Rozenblum R, De La Cruz BA, et al. Effect of an online weight management program
tion. Laparoscopic gastric banding is rarely used now because of the inferior integrated with population health management on weight change: a randomized clinical trial.
long-term weight loss results and late complications of band slippage, erosion, JAMA. 2020;324:1737-1746.
and weight regain. A9. Befort CA, Van Womer JJ, Desouza C, et al. Effect of behavioral therapy with in-clinic or telephone
After surgery, approximately 70% of patients achieve success, with almost group visits vs in-clinic individual visits on weight loss among patients with obesity in rural clinical
practice: a randomized clinical trial. JAMA. 2021;325:363-372.
all of the weight loss occurring during the first 1 to 2 years. Long-term (>5 year)
A10. Shi Q, Wang Y, Hao Q, et al. Pharmacotherapy for adults with overweight and obesity: a systematic
success rates are outstanding in good programs. Up to two thirds of patients review and network meta-analysis of randomised controlled trials. Lancet. 2022;399:259-269.
regain 20% or more of their maximum weight loss in the years following the A11. Frías JP, Davies MJ, Rosenstock J, et al. Tirzepatide versus semaglutide once weekly in patients
weight nadir, so postoperative weight regain remains an important clinical with type 2 diabetes. N Engl J Med. 2021;385:503-515.
challenge. Despite this regain, weight remains substantially below preoperative A12. Jastreboff AM, Aronne LJ, Ahmad NN, et al. Tirzepatide once weekly for the treatment of obesity.
levels for most patients. N Engl J Med. 2022;387:205-216.
Careful long-term follow-up is needed to ensure adequate protein, calorie, A13. Dahl D, Onishi Y, Norwood P, et al. Effect of subcutaneous tirzepatide vs placebo added to titrated
vitamin, and mineral nutrition. Supplemental vitamin B12, iron, and calcium are insulin glargine on glycemic control in patients with type 2 diabetes: the SURPASS-5 randomized
clinical trial. JAMA. 2022;327:534-545.
routinely added to standard multivitamins. The most common nutritional con-
A13b. Garvey WT, Frias JP, Jastreboff AM, et al. Tirzepatide once weekly for the treatment of obesity in
sequences of malabsorptive procedures are disorders of calcium and vitamin D people with type 2 diabetes (SURMOUNT-2): a double-blind, randomised, multicentre, placebo-
metabolism, although many severely obese patients have low vitamin D levels controlled, phase 3 trial. Lancet. 2023;402:613-626.
even before surgery (Chapter 226). An increase in the bone alkaline phospha- A13c. Wadden TA, Chao AM, Machineni S, et al. Tirzepatide after intensive lifestyle intervention in
tase level may signal deficiency of calcium or vitamin D. Low plasma vitamin adults with overweight or obesity: the SURMOUNT-3 phase 3 trial. Nat Med. 2023;29:2909-2918.
D levels and low urinary calcium excretion should prompt aggressive replace- A13d. Malhotra A, Grunstein RR, Fietze I, et al. Tirzepatide for the treatment of obstructive sleep apnea
ment therapy. Iron deficiency, other fat-soluble vitamin deficiencies, and copper and obesity. N Engl J Med. 2024. [Epub ahead of print.]
deficiency can occur more than 5 to 10 years after surgery. A14. Wilding JPH, Batterham RL, Calanna S, et al. Once-weekly semaglutide in adults with overweight
or obesity. N Engl J Med. 2021;384:989-1002.
Pancreatogenous hypoglycemia can develop after bariatric surgical
A15. Rubino D, Abrahamsson N, Davies M, et al. Effect of continued weekly subcutaneous semaglutide
procedures; symptoms are primarily postprandial and can be quite severe. vs placebo on weight loss maintenance in adults with overweight or obesity: the STEP 4 rand-
Medical management by specialists in this field is the best approach for omized clinical trial. JAMA. 2021;325:1414-1425.
these patients. A16. Davies M, Færch L, Jeppesen OK, et al. Semaglutide 2.4 mg once a week in adults with overweight
or obesity, and type 2 diabetes (STEP 2): a randomised, double-blind, double-dummy, placebo-
controlled, phase 3 trial. Lancet. 2021;397:971-984.
A16b. Wilkinson L, Holst-Hansen T, Laursen PN, et al. Effect of semaglutide 2.4 mg once weekly on 10-year
PREVENTION type 2 diabetes risk in adults with overweight or obesity. Obesity (Silver Spring). 2023;31:2249-2259.
The dramatic increase in the prevalence of obesity during the past few decades A16c. Wadden TA, Bailey TS, Billings LK, et al. Effect of subcutaneous semaglutide vs placebo as an
adjunct to intensive behavioral therapy on body weight in adults with overweight or obesity: the
strongly suggests that preventive strategies are needed. Public health approaches STEP 3 randomized clinical trial. JAMA. 2021;325:1403-1413.
that emphasize education have been almost uniformly unsuccessful at pre- A16d. Lincoff AM, Brown-Frandsen K, Colhoun HM, et al. Semaglutide and cardiovascular outcomes
venting weight gain or producing weight loss. Public health strategies that in obesity without diabetes. N Engl J Med. 2023;389:2221-2232.
A16e. Colhoun HM, Lingvay I, Brown PM, et al. Long-term kidney outcomes of semaglutide in obesity
virtually impose behavior change are more successful in this regard. Unless and cardiovascular disease in the SELECT trial. Nat Med. 2024;30:2058-2066.
widespread efforts are made to address the problem of obesity, it is likely that A16f. Kosiborod MN, Abildstrøm SZ, Borlaug BA, et al. Semaglutide in patients with heart failure with
its prevalence and complications will become an ever-increasing health burden. preserved ejection fraction and obesity. N Engl J Med. 2023;389:1069-1084.
A16g. Kosiborod MN, Petrie MC, Borlaug BA, et al. Semaglutide in patients with obesity-related heart
failure and type 2 diabetes. N Engl J Med. 2024;390:1394-1407.
PROGNOSIS A16h. Butler J, Shah SJ, Petrie MC, et al. Semaglutide versus placebo in people with obesity-related heart
On a population basis, life expectancy declines as BMI rises within the obese failure with preserved ejection fraction: a pooled analysis of the STEP-HFpEF and STEP-HFpEF
range. The loss of life is about 3 years for a BMI of 30 to 39, 7 years for a BMI of DM randomised trials. Lancet. 2024;403:1635-1648.
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40 to 44, 9 years for a BMI of 45 to 49, 10 years for a BMI of 50 to 54, and 14 and prevalent heart failure: a prespecified analysis of the SELECT trial. Lancet. 2024;404:773-786.
years for a BMI of 55 to 59. A16j. Alhindi Y, Avery A. The efficacy and safety of oral semaglutide for glycaemic management in adults
Individuals who cannot sustain lifestyle interventions or who become non- with type 2 diabetes compared to subcutaneous semaglutide, placebo, and other GLP-1 RA compara-
adherent to beneficial medications typically regain much or all of their lost tors: a systematic review and network meta-analysis. Contemp Clin Trials Commun. 2022;28:100944.
A16k. Knop FK, Aroda VR, do Vale RD, et al. Oral semaglutide 50 mg taken once per day in adults
weight. Long-term (>12 months) adherence is best with newer medications with overweight or obesity (OASIS 1): a randomised, double-blind, placebo-controlled, phase 3
(e.g., semaglutide and tirzepatide; about 40%), lower with phentermine/topiramate trial. Lancet. 2023;402:705-719.
or naltrexone/bupropion (about 10 to 15%), and very poor for orlistat.17b A16l. Mok J, Adeleke MO, Brown A, et al. Safety and Efficacy of liraglutide, 3.0 mg, once daily vs placebo
in patients with poor weight loss following metabolic surgery: the BARI-OPTIMISE randomized
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In markedly obese patients, however, bariatric surgery is associated with about A17. Rubino DM, Greenway FL, Khalid U, et al. Effect of weekly subcutaneous semaglutide vs daily
a 6-year increase in life expectancy compared with current medical manage- liraglutide on body weight in adults with overweight or obesity without diabetes: the STEP 8
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in adults with obesity : a randomized controlled trial. Ann Intern Med. 2024;177:549-558. A26b. Mok J, Adeleke MO, Brown A, et al. Safety and efficacy of liraglutide, 3.0 mg, once daily vs
A6. Villareal DT, Aguirre L, Gurney AB, et al. Aerobic or resistance exercise, or both, in dieting obese placebo in patients with poor weight loss following metabolic surgery: the BARI-OPTIMISE
older adults. N Engl J Med. 2017;376:1943-1955. randomized clinical trial. JAMA Surg. 2023;158:1003-1011.
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CHAPTER 201 Obesity 1470.e1
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JAMA. 2018;320:1163-1171.

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