Study Points
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Study Points
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- Define obesity and related conditions.
- Outline approaches to the clinical assessment of patients who are overweight or obese.
- Review the epidemiology of obesity, including the evolving obesity epidemic.
- Compare and contrast available energy expenditure research.
- Describe the role of diet, physical activity, and body mass index (BMI) on the etiology of obesity.
- Identify other etiologic factors contributing to the obesity epidemic.
- Evaluate current knowledge of energy balance and defense of body weight in the regulation of body weight.
- Define the four pillars of obesity management.
- Analyze pharmacotherapeutic options for monogenic obesity syndromes.
- Compare available pharmacotherapy for short- and long-term management of obesity.
- Identify investigational antiobesity medications in development.
- Review prescribing tips to improve the clinical use of antiobesity medications.
- Outline available metabolic and bariatric surgical interventions, including indications, contraindications, and efficacy.
- Discuss the role of endoscopic bariatric therapies in the management of obesity.
- Describe the physiology and pathophysiology underlying obesity and driving advances in the management of obesity.
A Black patient with a body mass index of 26 is considered overweight.
Click to ReviewBMI DEFINITIONS OF WEIGHT
Weight Category BMI Definition (kg/m2) Adult Adult, East Asian Pediatrica Underweight <18.5 <18.5 <5th percentile Normal 18.5–24.9 18.5–22.9 5th–85th percentile Overweight 25–29.9 23–24.9 ≥85th percentile Class I obesity 30–34.9 25–29.9 Obesity: ≥95th percentile
Class II obesity 35–39.9 30–34.9 Class III obesity (severe obesity) ≥40 ≥35 Severe obesity: ≥120% of the 95th percentile aBased on sex-specific BMI for age Increasing activity levels may bring diminishing returns due to compensatory responses in nonactivity energy expenditure.
Click to ReviewIncreasing activity levels may bring diminishing returns due to compensatory responses in nonactivity energy expenditure [66]. In 1,754 adults with DLW measured seven years apart, only 72% of the extra calories burned during activity translated into extra calories expended that day, because the body offset the calories burned in activities by 28%. Among those with BMI ≥34, compensation of burned activity calories increased to 46% [72].
The biological pressure to gain weight is a consequence of both increased appetite and suppressed energy expenditure as the body attempts to restore energy homeostasis.
Click to ReviewBecause both sides of the energy balance equation are affected after weight loss, the biological pressure to gain weight is a consequence of both increased appetite and suppressed energy expenditure as the body attempts to restore energy homeostasis [15,108]. Termed metabolic adaptation, this defense of established adiposity against weight loss recapitulates a physiological response that signals potential starvation [69,104].
Paroxetine is considered to be a weight-reducing antidepressant.
Click to ReviewOBESOGENIC MEDICATIONS AND WEIGHT-NEUTRAL OR -REDUCING ALTERNATIVES
Clinical Condition or Drug Class Weight-Promoting Weight Neutral Weight-Reducing Type 2 diabetes with obesity Pioglitazone Sulfonylureas Insulin DPP-4 inhibitors Metformin SGLT2 inhibitors GLP-1R agonists Antidepressants Paroxetine Amitriptyline Mirtazapine — Bupropion Fluoxetine Atypical antipsychotics Olanzapine Quetiapine Risperidone Ziprasidone — Anticonvulsants and mood stabilizers Divalproex Carbamazepine Gabapentin Lithium Lamotrigine Zonisamide Topiramate Inflammatory rheumatic diseases Corticosteroids DMARDs NSAIDs — DMARDs = disease-modifying antirheumatic drugs, DPP-4 = dipeptidyl peptidase-4, NSAIDs = nonsteroidal anti-inflammatory drugs, SGLT2 = sodium-glucose cotransporter-2. Each naltrexone/bupropion tablet contains naltrexone 90 mg plus bupropion 8 mg.
Click to ReviewEach naltrexone/bupropion tablet contains naltrexone 8 mg plus bupropion 90 mg. The target maintenance dose of 4 tablets daily (naltrexone 32 mg/bupropion 360 mg) daily is shortened with the prolonged-release formulation (NB32). The initial dose is 1 tablet daily, increased stepwise to the target of 2 tablets twice daily. Typical weight loss seen in practice is around 5% to 6% with NB32s [131].
Given this decreased likelihood of obesity in current cannabis users, research has begun to explore how the endocannabinoid system can be manipulated to promote weight loss and improve metabolic health.
Click to ReviewHowever, a meta-analysis of data from the National Epidemiologic Survey on Alcohol and Related Conditions and the National Comorbidity Survey-Replication found a decreased prevalence of obesity among current users of cannabis (≥3 days per week) of 14.3% and 17.2%, respectively [185]. Given this decreased likelihood of obesity in current cannabis users, research has begun to explore how the endocannabinoid system can be manipulated to promote weight loss and improve metabolic health.
Semaglutide 2.4 mg weekly is recommended as the first-line antiobesity medication for obesity management.
Click to ReviewGiven the significantly greater weight loss with semaglutide (15%) than other currently approved antiobesity medications (6% to 10%) and with 69% and 50% of subjects attaining weight loss ≥10% and >15%, respectively, semaglutide 2.4 mg weekly is recommended as the first-line antiobesity medication for obesity management [131]. Weight-loss goals for most individuals with obesity should be at least 10% or more, which is now achievable with current antiobesity medications.
Sleeve gastrectomy is optimally suited for a patient with lower BMI and no metabolic disease.
Click to ReviewASMBS-ENDORSED SURGICAL APPROACHES
Procedure Optimally Suited For Percent Excess Weight Lossa At 2 years At 10 years Roux-en-Y gastric bypass (RYGB) Higher BMI, GERD, diabetes 55% to 75% 52% to 69% Sleeve gastrectomy Metabolic disease 50% to 70% 67% to 71% Laparoscopic adjustable gastric banding (LAGB) Lower BMI, no metabolic disease 30% to 50% 38% to 47% Biliopancreatic diversion with duodenal switch (BPD/DS) Super-obesity (BMI ≥50), diabetes 63% to 80+% 68% Single anastomosis duodenal-ileal bypass with sleeve (SADI-S) Super-obesity 74% NA One-anastomosis gastric bypass (OAGB) Higher BMI, diabetes 68% to 80% 73% BMI = body mass index, GERD = gastroesophageal reflux disease, NA = not available. aMean average Orbera is an ASMBS-endorsed intragastric balloon device FDA-approved for six-month dwell-time.
Click to ReviewThree intragastric balloon devices are ASMBS-endorsed and FDA-approved for six-month dwell-time. The Orbera and Reshape balloons are both filled with methylene blue and saline. A leak or rupture releases the dye, which turns the urine blue to rapidly reveal the problem [135,228].
Contraindications to intragastric balloon devices use include prior abdominal or weight-reduction surgery, inflammatory bowel disease, obstructive disorders, GI ulcers, severe reflux, prior GI bleeding, severe liver disease, coagulopathy, ongoing alcohol use disorder, or intestinal varices, stricture, or stenosis [239,245].
Orbera, the most widely and longest used intragastric balloon device, is an endoscopically inserted single gastric balloon filled with 400–750 mL of fluid [245]. In a meta-analysis of 1,683 patients, weight loss at 6 and 12 months was 13.2% and 11.3%, respectively. Common adverse events were pain (34%), nausea (29%), GERD (18%), gastric mucosal erosion (12%), and balloon removal due to intolerability (7.5%). Severe events included gastric ulcers (2.0%), balloon displacement (1.4%), small bowel obstruction (0.3%), perforation (0.1%), and death (0.08%). All perforations occurred in patients with prior gastric surgery; all deaths were secondary to perforation or aspiration. Thus, individualized, detailed risk assessment is necessary for patients planning to undergo intragastric balloon device placement [228]. Orbera early removal is also associated with use of selective serotonin or serotonin-norepinephrine reuptake inhibitors (SSRIs/SNRIs) [125].
Ghrelin increases food consumption and reward.
Click to ReviewHORMONE, METABOLIC, AND PEPTIDE SIGNALS OF SATIETY, HUNGER AND ADIPOSITY, BY PERIPHERAL TISSUE ORIGIN
Hormone Receptor Locations in CNS Effects on Energy Balance and Obesity Adipocyte origin Adiponectin Hypothalamus ↓Body weight, plasma lipids Leptin ARC ↓Food intake, body weight Pancreatic cell origin Amylin ARC, AP, VTA, striatum ↑Satiety ↓Gastric emptying, food intake Glucagon (GCG) ARC, NTS ↑Satiety, glycogenolysis, gluconeogenesis Insulin ARC ↓Food intake, body weight Pancreatic polypeptide (PP) Hypothalamus, NTS ↑Satiety ↓Gastric emptying Enteroendocrine cell origin Cholecystokinin (CCK) Hypothalamus, NTS ↑Satiety ↓Gastric emptying/motility Ghrelin ARC ↑Food consumption and reward GIP ARC, PVH, DMH ↓Food intake ↑LPL, postprandial insulin Glucagon-like peptide-1 (GLP-1) ARC, NTS, AP, striatum ↑Satiety, postprandial insulin ↓Gastric emptying/motility, food reward Oxyntomodulin (OXM) Hypothalamus ↑Satiety ↓Gastric emptying, food intake Peptide tyrosine tyrosine (PYY) ARC, NTS ↑Satiety ↓Gastric emptying/motility AP = area postrema, ARC = arcuate nucleus of the hypothalamus, CNS = central nervous system, DMH = dorsomedial hypothalamus, GHSR, growth hormone secretagogue receptor, GIP, glucose-dependent insulinotropic polypeptide, NTS = nucleus tractus solitarius, PVH = paraventricular nucleus of the hypothalamus, VTA = ventral tegmental area.
- Back to Course Home
- Participation Instructions
- Review the course material online or in print.
- Complete the course evaluation.
- Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.