Long-Term Weight Loss Strategies for Obesity Kheniser, Karim; Saxon, David R; Kashyap, Sangeeta R
The journal of clinical endocrinology and metabolism,
07/2021, Volume:
106, Issue:
7
Journal Article
Peer reviewed
Open access
Abstract
Context
Obesity is a chronic disease that is difficult to manage without holistic therapy. The therapeutic armamentarium for obesity primarily consists of 4 forms of therapy: lifestyle ...modification (ie, diet and exercise), cognitive behavioral therapy, pharmacotherapy, and bariatric surgery.
Evidence acquisition
Evidence was consolidated from randomized controlled trials, observational studies, and meta-analyses.
Evidence synthesis
After 2 years, lifestyle interventions can facilitate weight loss that equates to ~5%. Even though lifestyle interventions are plagued by weight regain, they can have substantial effects on type 2 diabetes and cardiovascular disease risk. Although 10-year percentage excess weight loss can surpass 50% after bariatric surgery, weight regain is likely. To mitigate weight regain, instituting a multifactorial maintenance program is imperative. Such a program can integrate diet, exercise, and pharmacotherapy. Moreover, behavioral therapy can complement a maintenance program well.
Conclusions
Obesity is best managed by a multidisciplinary clinical team that integrates diet, exercise, and pharmacotherapy. Bariatric surgery is needed to manage type 2 diabetes and obesity in select patients.
Background Cognitive Behaviour Therapy (CBT) is the front-line psychological intervention for step 3 within UK psychological therapy services. Counselling is recommended only when other interventions ...have failed and its effectiveness has been questioned. Method A secondary data analysis was conducted of data collected from 33,243 patients across 103 Improving Access to Psychological Therapies (IAPT) services as part of the second round of the National Audit of Psychological Therapies (NAPT). Initial analysis considered levels of pre-post therapy effect sizes (ESs) and reliable improvement (RI) and reliable and clinically significant improvement (RCSI). Multilevel modelling was used to model predictors of outcome, namely patient pre-post change on PHQ-9 scores at last therapy session. Results Counselling received more referrals from patients experiencing moderate to severe depression than CBT. For patients scoring above the clinical cut-off on the PHQ-9 at intake, the pre-post ES (95% CI) for CBT was 1.59 (1.58, 1.62) with 46.6% making RCSI criteria and for counselling the pre-post ES was 1.55 (1.52, 1.59) with 44.3% of patients meeting RCSI criteria. Multilevel modelling revealed a significant site effect of 1.8%, while therapy type was not a predictor of outcome. A significant interaction was found between the number of sessions attended and therapy type, with patients attending fewer sessions on average for counselling M = 7.5 (5.54) sessions and a median (IQR) of 6 (3-10) than CBT M = 8.9 (6.34) sessions and a median (IQR) of 7 (4-12). Only where patients had 18 or 20 sessions was CBT significantly more effective than counselling, with recovery rates (95% CIs) of 62.2% (57.1, 66.9) and 62.4% (56.5, 68.0) respectively, compared with 44.4% (32.7, 56.6) and 42.6% (30.0, 55.9) for counselling. Counselling was significantly more effective at two sessions with a recovery rate of 34.9% (31.9, 37.9) compared with 22.2% (20.5, 24.0) for CBT. Conclusions Outcomes for counselling and CBT in the treatment of depression were comparable. Research efforts should focus on factors other than therapy type that may influence outcomes, namely the inherent variability between services, and adopt multilevel modelling as the given analytic approach in order to capture the naturally nested nature of the implementation and delivery of psychological therapies. It is of concern that half of all patients, regardless of type of intervention, did not show reliable improvement. Keywords: CBT, Counselling, Psychological therapy, Depression, Effectiveness, Efficiency
Full text
Available for:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objective
The aim of this study was to examine the prescribing patterns and use of antiobesity medications in a large cohort of patients using data from electronic health records.
Methods
Pharmacy‐ ...and patient‐level electronic health record data were obtained on 2,248,407 adults eligible for weight‐loss medications from eight geographically dispersed health care organizations.
Results
A total of 29,964 patients (1.3% of total cohort) filled at least one weight‐loss medication prescription. This cohort was 82.3% female, with median age 44.9 years and median BMI 37.2 kg/m2. Phentermine accounted for 76.6% of all prescriptions, with 51.7% of prescriptions being filled for ≥ 120 days and 33.8% filled for ≥ 360 days. There was an increase of 32.9% in medication days for all medications in 2015 compared with 2009. Higher prescription rates were observed in women, black patients, and patients in higher BMI classes. Of 3,919 providers who wrote at least one filled prescription, 23.8% (n = 863) were “frequent prescribers” who wrote 89.6% of all filled prescriptions.
Conclusions
Weight‐loss medications are rarely prescribed to eligible patients. Phentermine accounted for > 75% of all medication days, with a majority of patients filling it for more than 4 months. Less than one‐quarter of prescribing providers accounted for approximately 90% of all prescriptions.
Full text
Available for:
FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Abstract Statin intolerance is a commonly encountered clinical problem for which useful management strategies exist. Although many patients report statin-related muscle symptoms, studies indicate ...that the majority of these patients can tolerate a statin upon re-challenge. Alternative statin dosing strategies are an effective way to modify and reintroduce statin therapy for patients reporting adverse symptoms. Correction of vitamin D deficiency and hypothyroidism may improve statin tolerability in some patients. CoQ10 supplementation has been found to be of no benefit for statin-related muscle symptoms in most recent clinical trials. PCSK9 inhibitors are a new therapeutic option that if confirmed as safe and effective by outcomes trials may be of substantial benefit to select patients at high ASCVD risk who are unable to achieve adequate low-density lipoprotein cholesterol (LDL-C) lowering on maximally tolerated statin therapy. Other available medications to lower LDL-C in statin intolerant patients include ezetimibe, bile acid sequestrants, niacin, and fibrates.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Context:
Insulin autoimmune syndrome (IAS), or Hirata's disease, is a rare hypoglycemic disorder characterized by spontaneous hypoglycemia without evidence of exogenous insulin administration, a high ...serum concentration of total immunoreactive insulin, and the presence of insulin autoantibodies in high titer. The majority of cases occur in the Asian population, and treatment is generally successful with watchful waiting or steroids.
Case Description:
We report the case of a 71-year-old Caucasian man with severe hypoglycemia due to IAS that was refractory to a prolonged course of high-dose steroids. Type 1 diabetes prevention trials using rituximab have shown selective suppression of insulin autoantibodies, which are the pathogenic antibodies in IAS, and therefore we provided this therapy. Treatment with two doses of rituximab and daily use of a continuous glucose monitor resulted in disease remission.
Conclusion:
We present the first case where potentially life-threatening hypoglycemia due to IAS was successfully managed with rituximab and a continuous glucose monitor. We conclude that these treatment modalities are effective for the management of severe, refractory IAS.
We present the first case where potentially life-threatening hypoglycemia due to IAS was successfully managed with rituximab and a continuous glucose monitor. We conclude that these treatment modalities are effective for the management of severe, refractory IAS.
A previously published article in this journal reported the service effects from 103 services within the UK Improving Access to Psychological Therapies (IAPT) initiative and the comparative ...effectiveness of CBT and Counselling provision. All patients received High-intensity CBT or High-intensity Counselling, but some also received Low-intensity CBT before being stepped-up to High intensity treatments. The report did not distinguish between patients who received low-intensity CBT before being stepped-up. This article clarifies the basis for collapsing low- and high-intensity interventions by analysing the four treatment conditions separately.
Data from 33,243 patients included in the second round of the National Audit of Psychological Therapies (NAPT) were re-analysed as four separate conditions: High-intensity CBT only (n = 5975); High-intensity Counselling only (n = 3003); Low-intensity CBT plus High-intensity CBT (n = 17,620); and Low-intensity CBT plus High-intensity Counselling (n = 6645). Analyses considered levels of pre-post therapy effect sizes (ESs), reliable improvement (RI) and reliable and clinically significant improvement (RCSI). Multilevel modelling was used to model predictors of outcome, namely patient pre-post change on PHQ-9 scores at last therapy session.
Significant differences obtained on various outcome indices but were so small they carried no clinical significance. Including the four treatment groups in a multilevel model comprising patient intake severity, patient ethnicity and number of sessions attended showed no significant differences between the four treatment groups. Comparisons between the two high-intensity interventions only (N = 8978) indicated Counselling showed more improvement than CBT by 0.3 of a point on PHQ-9 for the mean number of sessions attended. However, this result was moderated by the number of sessions and for 12 or more sessions, the advantage went to CBT.
This re-analysis showed no evidence of clinically meaningful differences between the four treatment conditions using standard indices of patient outcomes. However, a differential advantage to high-intensity Counselling for fewer than average sessions attended and high-intensity CBT for more than average sessions attended has important service implications. The finding of equivalent outcomes between high-intensity CBT and Counselling for more severe patients also has important policy implications. Empirically-informed procedures (e.g., predictive modelling) for assigning patients to interventions need to be considered to improve patient outcomes.
Full text
Available for:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract
Despite professional society guidelines recommending that obesity be treated as a chronic disease by emphasizing the use of lifestyle modification in conjunction with pharmacotherapy, ...antiobesity medications are uncommonly prescribed in most clinical practices. The recent Food and Drug Administration approval of semaglutide 2.4 mg weekly to treat obesity—as well as other forthcoming advancements in diabetes and antiobesity medications—highlights the potential of pharmacotherapy to significantly augment weight loss efforts. In this Expert Endocrine Consult, we review the evolving role of antiobesity pharmacotherapy in clinical practice and suggest a framework for the use of these medications.
The worldwide rise in the prevalence of cardiometabolic disease, and the introduction of therapeutic options for treating metabolic disease that also lower cardiovascular risk, calls for a ...restructuring of how we care for patients with cardiometabolic disease. We propose establishment of a new medicine subspecialty, Cardiometabolic Medicine.
This summary is based on a synthesis of published original and review articles identified through PubMed, professional society guidelines, and the authors' knowledge of the fields of metabolism, diabetes, and cardiology.
The growing prevalence of cardiometabolic disease will continue to be perhaps the greatest challenge in the United States and throughout the world. We have entered an era where a large set of clinical tools are available that help prevent and treat cardiometabolic disease; however, our old models of clinical training and siloed care are barriers to rapid uptake and efficient healthcare delivery and are in need of change.
Establishing the field of Cardiometabolic Medicine would be a small step in the right direction towards providing the best possible comprehensive care for those with complex cardiometabolic disease.
Cardiovascular disease is a major cause of morbidity and mortality in patients with type 2 diabetes. For this reason, there is a great deal of interest in determining how therapies commonly used to ...treat patients with diabetes impact cardiovascular outcomes. Results from recently completed cardiovascular outcomes trials of diabetes agents from several medication classes are leading to a sea change in how we think about diabetes treatment. The primary focus of this paper is to review recently completed and ongoing diabetes medication cardiovascular outcomes trials. We also review cardiovascular outcome evidence for other classes of medications commonly used in patients with diabetes (i.e., aspirin, anti-hypertensive agents, lipid-lowering agents, and weight loss medications).
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, VSZLJ, ZAGLJ
Extension for Community Health Outcomes (ECHO) is a model of continuing medical education meant to connect academic medical center-based specialists with community providers to increase capacity in ...managing complex health conditions. The purpose of this study was to evaluate the effectiveness of a shortened "bootcamp" ECHO model in increasing participant competence with topics related to transgender and gender diverse (TGD) health care and the impact of "bootcamp" participation on enrollment in an ongoing ECHO series.
An ongoing monthly ECHO series was instituted on topics of TGD health. After 2 years, the team implemented a four-session "bootcamp" for four consecutive weeks during March 2022 to introduce foundational topics for new participants who had joined or were considering joining the ongoing series. Qualitative and quantitative results were collected from self-reported pre-/post-surveys as well as from in-session quizzes.
There were 71 participants in the "bootcamp" including health care providers and support staff. Attendees reported a 10.3% increase (
= 0.02) in self-reported comfort providing care to transgender patients. Pre-/post-knowledge improved in areas of health inequities (50% vs. 74% correct pre/post), surgical requirements (33% vs. 74%), and effects of masculinizing (55% vs. 70%) and feminizing (64% vs. 89%) hormone therapy. Prescribing providers reported a significant change across four areas of practice competency. Among 71 "bootcamp" participants, 15 registered for the ongoing program.
Use of a "bootcamp" highlights ways to increase participant comfort and knowledge in providing TGD health care in a shortened timeframe and recruit new participants to an ongoing ECHO curriculum.
PDF
