DESIRED OUTCOME

The goal of therapy should be reasonable and should consider initial body weight, patient motivation and desire, comorbidities, and patient age. If, for example, the primary goal is improved blood glucose, blood cholesterol, or hypertension, then the endpoint should be target levels of glycosylated hemoglobin, low-density lipoprotein cholesterol, or blood pressure; weight loss goals may be as little as 5%. If the primary goal is relief of osteoarthritis or sleep apnea, then weight loss of 10% or 20% may be more appropriate.

TABLE 59-1

Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risk
BMI (kg/m2) Obesity Class Disease Riska (Relative to Normal and Waist Circumference) Men 40 in. (102 cm) Women 35 cm) inches inches cm) cm)

Underweight Normalb Overweight Obesity obesity

a bIncreased

<18.5 18.524.9 25.029.9 30.034.9 35.039.9 40

Increased high high high high high

Disease risk for type 2 diabetes, hypertension, and cardiovascular disease. waist circumference can also be a marker for increased risk even in persons of normal weight.

TREATMENT
Successful obesity treatment plans incorporate diet, exercise, behavior modification with or without pharmacologic therapy, and/or surgery (Fig. 59-1). The primary aim of behavior modification is to help patients choose lifestyles conducive to safe and sustained weight loss. Behavioral therapy is based on principles of human learning, which use stimulus control and reinforcement to substitute desirable for learned, undesirable behavior. Many diets exist to aid weight loss. Regardless of the program, energy consumption must be less than energy expenditure. A reasonable goal is loss of 0.5 to 1 kg per week with a diet balanced in fat, carbohydrate, and protein intake. Surgery, which reduces the stomach volume or absorptive surface of the alimentary tract, remains the most effective intervention for obesity. Although modern techniques are safer than older procedures and have an operative mortality of 1%, there are still many potential complications. Therefore, surgery should be reserved for those with BMI greater than 35 or 40 kg/m2 and significant comorbidity.

PHARMACOLOGIC THERAPY
(Table 59-2) The debate regarding the role of pharmacotherapy remains heated, fueled by the need to treat a growing epidemic and by the fallout from the removal of several agents from the market because of adverse reactions. The National Task Force on the Prevention and Treatment of Obesity concluded that short-term use of anorectic agents is difficult to justify because of the predictable weight regain that occurs upon discontinuation. Long-term use may have a role for patients who have no contraindications, but further study is needed before widespread, routine use is implemented. Orlistat induces weight loss by lowering dietary fat absorption, and it also improves lipid profiles, glucose control, and other metabolic markers. Soft stools, abdominal pain or colic, flatulence, fecal urgency, and/or incontinence occur in 80% of individuals, are mild to moderate in severity, and improve after 1 to 2 months of therapy. Orlistat interferes with the absorption of fat-soluble vitamins and cyclosporine. Sibutramine is more effective than placebo with the most significant weight loss during the first 6 months of use. Dry mouth, anorexia, insomnia, constipation, increased appetite, dizziness, and nausea occur two to three times more often than with placebo. Sibutramine should not be used in patients with coronary artery disease, stroke, congestive heart failure, arrhythmias, or monoamine oxidase inhibitor use. Phentermine (30 mg in the morning or 8 mg before meals) has less powerful stimulant activity and lower abuse potential than amphetamines and was an effective adjunct in placebo-controlled studies. Adverse effects (e.g., increased blood pressure, palpitations, arrhythmias, mydriasis, altered insulin or oral hypoglycemic requirements) and interactions with monoamine oxidase inhibitors have implications for patient selection.

 Diethylpropion (25 mg before meals or 75 mg of extended-release formulation every morning) is more effective than placebo in achieving short-term weight loss. Diethylpropion is one of the safest noradrenergic appetite suppressants and can be used in patients with mild to moderate hypertension or angina, but it should not be used in patients with severe hypertension or significant cardiovascular disease. Amphetamines should generally be avoided because of their powerful stimulant and addictive potential. Herbal, natural, and food-supplement products are often used to promote weight loss (Table 59-3). The FDA does not strictly regulate these prod- ucts, so the ingredients may be inactive and present in variable concentrations. After more than 800 reports of serious adverse events (e.g., seizures, stroke, and death) were attributed to ephedrine alkaloids, the FDA decided to exclude them from dietary supplements.