Prescribing Weight Loss

Obesity is a chronic medical condition that significantly increases the risk of type 2 diabetes, cardiovascular disease, hypertension, and certain cancers. Effective management requires a patient-centered approach that combines lifestyle interventions, pharmacotherapy, and, in some cases, surgical options. Below is a guide for healthcare professionals on prescribing weight loss therapies for obesity.

1. When to Intervene

a. Diagnosis of Obesity

• BMI Criteria:
  • Overweight: BMI 25–29.9 kg/m².
  • Obesity: BMI ≥30 kg/m².
• Waist Circumference:
  • Increased risk: >102 cm (men), >88 cm (women).

b. Indications for Pharmacotherapy

• BMI ≥30 kg/m² or
• BMI ≥27 kg/m² with obesity-related comorbidities (e.g., diabetes, hypertension, obstructive sleep apnea).

2. Goals of Weight Loss Therapy

1. Achieve a 5–10% reduction in body weight within the first 6 months.
2. Improve obesity-related comorbidities.
3. Maintain weight loss and prevent regain.

3. Treatment Modalities

a. Lifestyle Modifications

Lifestyle changes are the cornerstone of obesity management and must accompany any pharmacological or surgical intervention.

1. Diet

• Create a caloric deficit of 500–750 kcal/day.
• Focus on:
  • High-protein, low-glycemic foods.
  • Whole grains, lean proteins, fruits, vegetables.
  • Reducing refined sugars and saturated fats.
• Structured meal plans (e.g., Mediterranean diet, DASH diet) can improve adherence.

2. Physical Activity

• Aim for 150–300 minutes/week of moderate-intensity aerobic exercise.
• Incorporate resistance training 2–3 times/week to preserve muscle mass.

3. Behavioral Therapy

• Use cognitive-behavioral techniques to address emotional eating and build healthy habits.
• Set realistic, achievable goals.

b. Pharmacological Therapy

Prescription weight-loss medications are appropriate for patients who do not achieve sufficient weight loss through lifestyle changes alone.

1. GLP-1 Receptor Agonists

• Examples: Semaglutide, Liraglutide.
• Mechanism:
  • Mimics the incretin hormone GLP-1 to reduce appetite and caloric intake.
• Dosage:
  • Semaglutide: Start at 0.25 mg once weekly, titrate to 2.4 mg.
  • Liraglutide: Start at 0.6 mg/day, titrate to 3.0 mg/day.
• Efficacy: 10–15% weight loss over 12 months.
• Side Effects:
  • Nausea, vomiting, diarrhea.
  • Rare: Pancreatitis.
• Precautions:
  • Avoid in patients with a history of medullary thyroid carcinoma or pancreatitis.

2. Orlistat

• Mechanism:
  • Inhibits gastrointestinal lipase, reducing fat absorption by ~30%.
• Dosage:
  • 120 mg three times daily with meals.
• Efficacy: 5–7% weight loss over 12 months.
• Side Effects:
  • Gastrointestinal: Flatulence, oily stools, diarrhea.
• Precautions:
  • Take a multivitamin to replace fat-soluble vitamins (A, D, E, K).

3. Naltrexone-Bupropion

• Mechanism:
  • Acts on appetite and reward centers in the brain.
• Dosage:
  • Start with 8 mg/90 mg daily, titrate to 16 mg/180 mg twice daily.
• Efficacy: 5–9% weight loss over 12 months.
• Side Effects:
  • Nausea, headache, dizziness, insomnia.
• Precautions:
  • Contraindicated in uncontrolled hypertension, seizure disorders.

4. Phentermine-Topiramate ER

• Mechanism:
  • Combines appetite suppression with enhanced satiety.
• Dosage:
  • Start with 3.75 mg/23 mg daily, titrate to 15 mg/92 mg.
• Efficacy: 8–12% weight loss over 12 months.
• Side Effects:
  • Insomnia, dry mouth, dizziness, constipation.
• Precautions:
  • Avoid in pregnancy; teratogenic.

c. Surgical Options

Bariatric surgery is recommended for patients with severe obesity when other interventions fail.

1. Indications

• BMI ≥40 kg/m² or
• BMI ≥35 kg/m² with significant comorbidities.

2. Types of Surgery

• Roux-en-Y Gastric Bypass:
  • Creates a small stomach pouch and bypasses part of the small intestine.
• Sleeve Gastrectomy:
  • Removes a portion of the stomach, reducing its size.
• Adjustable Gastric Banding:
  • Places a band around the upper part of the stomach.

3. Outcomes

• 20–35% weight loss within 2 years.
• Significant improvement in diabetes, hypertension, and other comorbidities.

4. Monitoring and Follow-Up

a. Weight Monitoring

• Track weight at least every 4–6 weeks during active weight loss.
• Monitor every 3–6 months during maintenance.

b. Metabolic Parameters

• Regularly assess:
  • Blood glucose levels.
  • Lipid profile.
  • Blood pressure.

c. Medication Side Effects

• Evaluate for adverse effects and adjust dosages as necessary.

5. Patient Counselling

a. Adherence to Therapy

• Stress the importance of consistency in lifestyle changes and medication use.

b. Managing Expectations

• Set realistic weight-loss goals (5–10% reduction).
• Explain that even modest weight loss improves health significantly.

c. Addressing Plateaus

• Encourage continued adherence to diet and exercise during weight-loss plateaus.
• Consider revising medication or adding therapy.

d. Support System

• Encourage family involvement and participation in weight-loss programs.

6. FAQs

Q1: What is the best medication for weight loss?

• GLP-1 receptor agonists like Semaglutide and Liraglutide are highly effective, with weight loss of 10–15% over a year.

Q2: Can lifestyle changes alone help with obesity?

• For mild cases, yes. However, combining lifestyle changes with medications improves outcomes for most patients.

Q3: How much weight should I lose to improve my health?

• A weight loss of 5–10% significantly reduces the risk of diabetes, heart disease, and joint problems.

Q4: Is bariatric surgery safe?

• Yes, when performed in suitable patients, bariatric surgery is safe and highly effective in managing severe obesity.

Q5: Are weight-loss medications permanent solutions?

• Medications aid in achieving and maintaining weight loss but should be paired with sustainable lifestyle changes.

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7. Key Takeaways

• Start with lifestyle modifications and escalate to pharmacotherapy or surgery if needed.
• Regular monitoring and follow-up are critical for success.
• Tailor therapy to individual needs, comorbidities, and preferences.

Conclusion

Effective weight loss therapy for obesity involves a comprehensive approach that combines dietary changes, exercise, behavioral strategies, and medical interventions. By addressing the root causes and tailoring treatment plans, healthcare professionals can help patients achieve and maintain a healthy weight, improving their quality of life and reducing the burden of obesity-related diseases.

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