Weight Management in Obese Individuals with Common Comorbid Conditions

Two calculations used to determine a patient’s body fat are body mass index (BMI) and waist-to-hip ratio. The BMI calculates body fat based on a patient’s height and weight (Figure),¹ and the waist-to-hip ratio calculates a patient’s health risk based on how body fat is distributed (Table 1). The waist-tohip ratio classifies the risk of developing health problems associated with obesity, such as diabetes, coronary heart disease, and high blood pressure.² Overweight individuals have a BMI between 25.0 and 29.9 kg/m², whereas obese individuals have a BMI ≥30 kg/m².³ In the United States, total health expenditures secondary to obesity may reach $344 billion by 2018 and 16% to 18% of health care costs by 2030.⁴

The clinical burdens of male obesity in the United States continue to be heavy. In 2014, 70% of American males had a BMI >25 kg/m². Moreover, between 2011 and 2012, about one-third of men were classified as obese.^5,6 The rise in the incidence of obesity in men can be attributed to multiple factors, most notably modern lifestyle choices that include the consumption of inexpensive unhealthy foods, a sedentary lifestyle, and environmental factors that limit access to a healthy diet and exercise.⁷

Patients who are obese are more likely to develop chronic conditions such as diabetes, hypertension, and heart disease.⁸ Among men, complications secondary to obesity may include a decreased testosterone level, erectile dysfunction, impaired fertility, kidney stone development, benign prostatic hyperplasia, a decreased prostate-specific antigen level, and an increased risk of prostate cancer.² This article reviews weight loss treatments and outcomes for secondary complications from obesity and offers community pharmacists interventions for weight management therapy.

PHARMACOTHERAPY: WEIGHT MANAGEMENT

FDA-approved pharmacologic options for weight management in patients classified as obese (used alongside behavioral modification and caloric restriction) include phentermine, orlistat, and phentermine/ topiramate.^9-11 Drugs that are not FDA-approved for weight management in these patients include exenatide, liraglutide, topiramate, lamotrigine, zonisamide, and bupropion.

Lifestyle recommendations include following exercise and diet plans approved by health care professionals and certified professional trainers. Diet, physical activity, and behavior therapy designed to achieve 5% weight loss are recommended for overweight and obese individuals with type 2 diabetes (T2D) who are motivated to lose weight. Strategies for patients who are highly motivated to adhere to a weight management program include a focus on diet, physical activity, and behavioral strategies to reduce calorie consumption by 500 to 750 per day. Pharmacists should warn patients against using weight-loss supplements because the FDA has not approved any such supplements for weight management.¹²

AMERICAN DIABETES ASSOCIATION 2016 GUIDELINE RECOMMENDATIONS

Among evidence-based guidelines, the American Diabetes Association (ADA) 2016 guidelines effectively describe how to manage obesity in patients with T2D.¹³ Antihyperglycemic medications, such as insulin or thiazolidinediones, may affect weight in individuals with T2D who are overweight or obese. Therefore, clinicians may want to consider how medications, especially antihyperglycemics, affect weight.

In patients with T2D and a BMI ≥27 kg/m², weight loss medications may be effective as adjuncts to diet, physical activity, and behavioral counseling. If patients taking weight loss medications do not lose more than 5% of their body weight after 3 months or cannot tolerate these medications, it is recommended that these patients either discontinue the medication or use an alternative treatment.

OBESITY OUTCOMES IN COMORBID CONDITIONS

In overweight/obese patients on a weight management regimen, successful outcomes have been demonstrated in patients with comorbid conditions with or without the use of orlistat.

Diabetes

In overweight and obese adults at risk for T2D, those who lost an average of 2.5 to 5.5 kg beyond 2 years (with lifestyle intervention) reduced their risk of developing T2D by 30% to 60%. Moreover, in overweight and obese adults with T2D, a 2% to 5% weight loss achieved within 1 to 4 years after lifestyle intervention reduced glycated hemoglobin (A1C) by 0.2% to 0.3%; these patients were also more likely to have clinically significant fasting blood glucose reductions (>20 mg/dL) than those who remained weight stable (defined as gaining ≤2% or losing <2% of body weight). Adults who lost 5% to 10% of body weight reduced their A1C by 0.6% to 1%, as well as their need for antihyperglycemics. Finally, compared with patients who took a placebo, overweight or obese adults with T2D who took orlistat lost an additional 3 kg of weight, reduced their fasting blood glucose levels by about 11 mg/dL within 2 years, and reduced their A1C by 0.4% at 1 year.14 These data show that adherence to guideline recommendations and prescription of orlistat improved weight loss outcomes in overweight or obese patients with, or at risk for, T2D.

Hypertension

In overweight or obese adults with elevated risk for cardiovascular disease (CVD), including those with T2D and hypertension, there is a direct correlation between the weight patients lost at up to 3 years through lifestyle intervention (with or without orlistat) and their blood pressure reduction. These patients, who lost 5% of their weight, reduced their systolic and diastolic blood pressure by about 3 and 2 mm Hg, respectively.¹⁴

Hyperlipidemia

In overweight or obese adults with or without an elevated CVD risk, there is a strong relationship between how much weight patients lost via lifestyle interventions and improvements in their lipid profile. At a 3-kg weight loss, a weighted mean reduction in triglycerides of at least 15 mg/dL was observed. Moreover, patients who lost between 5 and 8 kg reduced their low-density lipoprotein cholesterol by about 5 mg/dL and increased their high-density lipoprotein cholesterol by about 3 mg/dL.¹⁴

PHARMACIST-LED INTERVENTIONS

Along with calculating BMI and waist-to-hip ratio, pharmacists can implement several interventions for their weight management medication therapy management services. Pharmacists can discontinue or change medications associated with weight gain and vigilantly evaluate diseases that obesity may complicate. Pharmacists should also ask the appropriate questions when counseling overweight or obese patients (Online Table 2).¹⁵ In addition, before pharmacists implement a weight management program at their pharmacy, they should account for, and develop solutions to overcome, barriers that may emerge. Barriers to implementing weight management programs may include the following: a pharmacist’s knowledge of obesity and weight-loss management; a pharmacy’s resources, time, and business model; and the patient’s preference, comfort level, and access to unhealthy foods.¹⁶

Table 2. Sample Questions Used to Effectively Counsel Overweight Patients

Purpose

Sample Questions

Assess ambivalence and motivation for lifestyle change

· How ready do you feel to change your eating patterns and/or lifestyle behaviors?

· What kinds of things have you done in the past to change your diet?

· How much of you is not wanting to change?

· What makes you feel like you can continue to make progress if you decide to?

Readiness to change

· People differ in how ready they are to make these kinds of changes. How ready are you?

· How would you like your health to be different?

· Some people don’t want to talk about their weight at all, whereas some people don’t mind. How do you feel about this?

Importance of change

· Tell me how things would be different for you if you (were at a healthier weight, etc)?

· What would have to happen before you seriously considered changing?

· What concerns do you have about (losing weight, eating healthier, exercising more)?

Building confidence

· What would make you more confident about making these changes?

· How can I help you succeed?

· What are some practical things that you need to do to achieve this goal?

Barriers

· What things stand in the way of your taking a first step?

· What barriers might impede success (eg, child care, transportation, distance, cost, accessibility)?

Pharmacists should determine plans for individuals who want to achieve either short- or long-term weight loss. Based on the ADA 2016 guidelines, individuals who achieve short-term weight loss should be placed on a long-term (more than 1 year) comprehensive weight management program.¹³ Moreover, it is recommended that pharmacists contact these patients at least monthly and continue to monitor body weight. Pharmacists who want patients to achieve short-term weight loss should prescribe high-intensity lifestyle interventions that use low-calorie diets (fewer than 800 calories per day) and call for extensive physical activity (200-300 min/week), with the goal of losing 5% to 10% of their body weight. When patients achieve their short-term goals, pharmacists may consider counseling patients to pursue a long-term comprehensive weight management program to maintain weight loss.

Brian J. Catton, PharmD, graduated from the Bernard J. Dunn School of Pharmacy at Shenandoah University in Winchester, Virginia, in 2010. He received the Distinguished Young Pharmacist Award from the New Jersey Pharmacists Association in 2014 and founded its New Practitioner Network in 2015. He is currently a pharmacist communicator at Ashfield Healthcare in Ivyland, Pennsylvania. His areas of interest include pediatrics, immunizations, drug-therapy management, social media, patient counseling, and immuno-oncology.

References

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• 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.
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• Harmon M, Pogge E, Boomershine V. Evaluation of a pharmacist-led, 6-month weight loss program in obese patients. J Am Pharm Assoc. 2014;54(3):302-307. doi: 10.1331/JAPhA.2014.13138.
• Adipex-P tablets [package insert]. Sellersville, PA: Teva Pharmaceuticals; 2012.
• Xenical (orlistat) capsules [package insert]. South San Francisco, CA: Genentech USA, Inc; 2016.
• Qsymia (phentermine and topiramate extended-release) capsules [package insert]. Mountain View, CA: VIVUS, Inc; 2014.
• Beware of products promising miracle weight loss. FDA website. www.fda.gov/ForConsumers/ConsumerUpdates/ucm246742.htm. Updated July 25, 2015. Accessed August 16, 2016.
• American Diabetes Association. Obesity management for the treatment of type 2 diabetes. Diabetes Care. 2016;39(suppl 1):S47-S51. doi: 10.2337/dc16-S009.
• 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(25 Pt B):. doi:10.1016/j.jacc.2013.11.004.
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