The proportion of severely overweight or obese patients is steadily increasing. The common disease is seen more of a health disorder resulting from an unhealthy lifestyle. However, the consequences can be dramatic. Obesity is one of the most important causes of significant secondary diseases such as hypertension, diabetes mellitus or coronary heart disease. Multimodal therapy management can help.
Obesity, defined as a greater than normal increase in body fat above a BMI >30, is very common worldwide. The fact that the prevalence has doubled in the last 30 years should be taken seriously, reported Eleonora Seelig, MD, Liestal. There are major differences: while 20-30% of the population in the USA is obese, the figure in West/East Africa, Japan or even India is less than 5%. With a share of 10%, Switzerland is in the middle of the pack. In 2018, the Swiss Health Survey found that 10.2% of women were obese and 12.3% of men. If the proportion of overweight men is added, every second man in Switzerland weighs more than his normal weight. These numbers are alarming because morbidity and mortality are significantly increased in obese patients. For example, with a BMI of 40-45, life expectancy is reduced by eight to ten years. This naturally also has an impact on costs, which were around CHF 8 billion in 2012.
But why is humanity getting heavier and heavier? Both genes and the environment have an influence on physical stature. In fact, obesity has been found to be heritable. However, environmental factors are considered to be the main cause of increased body weight. A big problem is the overstimulation and the constant exposure to temptations. In a very elaborate study in the USA, the eating behavior of healthy, slim adults was linked to their weight history. The follow-up ran for 20 years. On average, subjects gained 1.5 kg over four years. However, there were large differences depending on the eating behavior. An unhealthy diet was clearly more noticeable on the scales than a healthy diet. Accordingly, the quality of the food plays a decisive role. In a small study, 20 subjects were each exposed for two weeks to either an ultra-processed diet with processed foods or unprocessed diet. The latter involved fresh cooking. Both diets were absolutely comparable in terms of composition and caloric intake. Nevertheless, body weight increased significantly during the two weeks with processed food, while it decreased with freshly cooked food.
Focus on multimodal therapy management
Seelig used a case study to illustrate the individual steps of therapy management. A 26-year-old female patient complained of steady weight gain. At the time of consultation, she weighed 98 kg at 175 cm tall, which corresponds to a BMI of 32. She was not taking any medications and did not report any underlying conditions. Family history was positive for obesity. The search for tangible triggers began. In addition to medications, these include hypothyroidism, chushing syndrome, dysfunctions in the hypothalamus, or gene defects. The goal of weight loss includes risk reduction in terms of morbidity as well as improvement in quality of life. This can be achieved using a treatment management approach built on lifestyle intervention, pharmacotherapy, and bariatric surgery.
Lifestyle intervention focuses on sustainable change in eating and physical activity behaviors. This can be achieved through frequent and brief contacts that provide information and coach the patient. This can be carried out by the doctor as well as a nutritionist, psychologist and fitness coach. Meals should be structured and have a balanced composition. In terms of weight loss, all common diets have proven to be similarly effective, the expert said. The individually ideal diet is therefore the one that can be maintained over the long term. However, with regard to cardiovascular benefits, the Mediterranean diet has been established as particularly effective. In addition, to achieve long-term weight stabilization and favorable metabolic effects, daily activities should be increased and regular exercise should be practiced.
Pharmacological support for weight loss
Lifestyle education should be provided to all obese patients. Nevertheless, the limits must be seen here as well – very few patients achieve satisfactory weight reduction solely on the basis of a change in eating and exercise behavior. In addition, the process can be supported by administration of a GLP-1 analog. Originally used in diabetes therapy, it not only improves insulin secretion but also reduces the feeling of hunger in the brain. In a study of 3700 obese patients, administration of 3.0 mg liraglutide versus placebo in addition to diet and exercise demonstrated significantly greater weight loss (8.4 ± 7.3 kg vs. 2.8 ± 6.5 kg). The addition of the GLP-1 analogue to the therapy management requires a cost approval by the specialist. Prerequisites are a BMI ≥35 (or ≥28 for additional obesity-associated comorbidities), participation in an obesity program, no prior treatment with a GLP-1 analog, and no planned or previously performed bariatric surgery.
Bariatric surgery is an option for patients with a BMI of 35 or higher and unsuccessful weight loss attempts over two years. If this measure is carried out, the weight reduction is usually 20-30% of the initial weight. However, this can vary greatly from individual to individual. A slight rebound effect after one to two years is possible. A significant reduction in mortality is achieved and a reduction in morbidity. The quality of life improves due to weight reduction.
Source: Forum for Continuing Medical Education
CARDIOVASC 2021; 20(1): 34 (published 3/3/21, ahead of print).
