Medical Weight Management
GOAL OF MEDICAL WEIGHT MANAGEMENT
People with a BMI greater than 27kg/m2 who have a weight-related comorbidity or people who have a BMI greater than 30kg/m2 with or without a weight-related comorbidity should be considered for formal weight loss efforts. The primary goal of medical weight management of obesity is achieving a weight reduction of 7%–10%. Secondary goals include improving metabolic outcomes, reducing no-show rates, achieving satisfaction, and limiting or eliminating disease comorbidities. Even a modest, sustained weight loss of 3%–5% can improve clinical outcomes (e.g., reduction in triglycerides, blood glucose and type 2 diabetes risk).17 When a larger volume of weight is lost, there are further reductions in risk factors of cardiovascular disease (CVD) (e.g., low-density and high-density lipoprotein cholesterol and blood pressure) and the need for medication to control previously diagnosed CVD and type 2 diabetes.17 Therefore, a weight loss goal of 5%–10% of total body weight within six months of management is recommended.17
TRIAGE AND ASSESSMENT
Primary Care Initial Screening and Diagnosis (see Algorithm 1)
All adults should be screened annually for obesity using a BMI measurement. Other methods (e.g., bioelectric impedance, air/water displacement plethysmography) to determine adiposity may be used at the clinician’s discretion if BMI results are equivocal or require further evaluation.18 Screening and diagnosis typically occur through primary care providers, who can offer basic weight management treatment options (see tables 2 and 3 for details). It is recommended that the primary care provider offer education sources and tools (see section V) to the patient. Based on obesity status and risk factors, the provider and patient should engage in joint decision-making for medical or surgical management.
- New patient obesity bloodwork. At minimum, glucose, lipid and endocrine profiles are recommended for every weight-management-program patient.17 If basic labs are available within the last 12 months, bloodwork is at the discretion of the provider.
- Consultation with a registered dietitian should be also be completed on this visit if possible.
Prompt Initiation of Anti-Obesity Medications
Vanderbilt Health Affiliated Network recommends prompt initiation of anti-obesity medications per The Journal of Clinical Endocrinology & Metabolism guidelines for all patients with a BMI of greater than 27 kg/m2 with comorbidity or BMI greater than 30 kg/m2. Medications are to be used as adjuncts to behavioral modification and reducing food intake.19 Weight loss medications can improve adherence to behavioral changes and may improve physical function so that physical activity is easier in those who cannot initially exercise due to their weight.19
Patients who have been unsuccessful in the past with weight loss and those who meet label indications are candidates for weight loss medication.19
Referral to Medical Nutrition Therapy and Group Therapy
Dietary modifications are an integral part of any successful weight-loss program. Each patient needs an in-depth individualized nutrition plan and should be referred to Medical Nutrition Therapy (MNT) provided by a registered dietitian (RD). MNT is a nutritional diagnostic, therapy and counseling service for the purpose of disease management.20 MNT aims to help patients lose weight, maintain weight loss, and meet goals for blood pressure, cholesterol and glycemic targets. MNT is also often employed to delay or prevent diabetes complications.21 If MNT is unavailable or cannot be achieved, apps or other free resources may provide an option (see section IV, Educational Resources).
The American Academy of Nutrition and Dietetics recommends both decreasing energy intake and enhancing dietary quality, along with undertaking regular physical activity (150 minutes/week of moderate physical activity or 75 minutes/week of vigorous physical activity, followed by a maintenance routine of more than 250 minutes per week of moderate-to-vigorous physical activity) as essential to initiate and sustain weight loss.17
Evidence-proven dietary interventions to support weight loss include reducing caloric intake—especially of sweetened drinks—monitoring portions, engaging in low-carbohydrate, high-protein eating patterns and following proven eating plans, such as the DASH and Mediterranean plans, in concert with calorie restriction. It is important to note that, without accompanying caloric restriction, diets that restructure macronutrient intake, including the DASH and Mediterranean diets, have not been found to contribute to weight loss.17
The American Academy of Nutrition and Dietetics considers the following recommendations imperative for people who want to achieve sustained weight loss:17
- Women should be encouraged to aim for between 1,200–1,500 kcal/day, while men should aim for 1,500–1,800 kcal/day; alternatively, people should aim for a deficit of 500–750 kcal/day. Diets should provide adequate nutrition in combination with reduced calorie intake.
- Patients should be reminded that many healthy diets can help them lose weight, as long as they fall within the calorie-deficit parameters of 500–700 kcal/day.
- After weight loss, providers should help patients plan an individualized maintenance diet, representing both adequate nutrition and reduced caloric intake to sustain their lower body weight.*
- Similarly, patients should be reminded that many healthy diets can help them sustain weight loss, as long as they fall within calorie-deficit parameters of 500–700 kcal/day.
*Substantial weight loss through diet and exercise can decrease the initial RMR used for caloric intake calculations. Maintaining weight loss in the maintenance stage may require fewer calories than initially calculated or high levels of physical activity due to this metabolic adaptation.22
Individual and/or Group Exercise Motivation Class
A sedentary lifestyle and obesity are closely linked. People who struggle with obesity may be ashamed to work out on their own due to stigmatization of obese individuals in society. Group exercise classes allow obese patients to exercise without the stigma. Beyond weight loss, participation in group fitness classes has been found to lead to a decrease in perceived stress and an increase in physical, mental and emotional quality of life compared to exercising independently or not engaging in regular physical activity at all.23
Drug-Induced Weight Gain
A thorough medication reconciliation should be completed during the initial consult to identify medications that can contribute to weight gain. Common medication classes that cause weight gain include contraceptives, antidepressants, atypical antipsychotics and some diabetes medications.19 Other medication classes with similar effects include beta blockers and corticosteroids.19 Alternative medications that limit or eliminate weight gain potential should be considered and weighed against patient risk factors for obesity-related health complications.19 Providers must keep this consideration in mind when prescribing first-line therapy or making medication changes.
It is important to have regular, established visits during a medical weight management program to reinforce behavioral and lifestyle changes and monitor progress. The visit pattern is monthly for the first six months, trimonthly for one year, then every 6–12 months.
Surgical Weight-Loss Pathway
Some patients should be considered for bariatric surgery as an initial weight loss therapy based on comorbidity and total weight loss needs. If medical management is not successful or if patients request a conversation about surgery, then they should be referred for consultation for surgical management.