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James S. Yeh, M.D., M.P.H., Robert F. Kushner, M.D., and Gordon D. Schiff, M.D.
TREATMENT OPTIONS
Which of the following treatment options would you recommend for this patient?
1. Start lifestyle modification and therapy with an FDA-approved drug.
2. Maximize lifestyle modification and nonpharmacologic therapies.
To aid in your decision making, each of these approaches is defended in a short
essay by an expert in the field. Given your knowledge of the patient and the
points made by the experts, which option would you choose? Factor into your
decision the indications for pharmacologic therapies for weight loss, differences
among the various weight-loss medications, concerns about their long-term
efficacy and safety, and the role of adjuvant lifestyle and nonpharmacologic
therapies in promoting and maintaining weight loss.
Option 1: Start Lifestyle Modification and Therapy with an FDA-Approved Drug
Option 2: Maximize Lifestyle Modification and Nonpharmacologic Therapies
OPTION 1
Start Lifestyle Modification and Therapy with an FDA-Approved Drug
Robert F. Kushner, M.D.
Disclosure forms provided by the author are available with the full text of this
article at NEJM.org.
SOURCE INFORMATION
From the Department of Medicine, Northwestern University Feinberg School of Medicine,
Chicago.
65 Reader's Comments
ANALYSIS OF POLLING RESULTS
Polling and commenting closed October 6, 2016. We received 905 responses to
the poll and posted 64 of your comments. An analysis of the polling results
appears below. — Edward W. Campion, M.D., Executive Editor
Editor's Comment
Obesity and Management of Weight Loss — Polling Results James Yeh, M.D.,
M.P.H., and Edward W. Campion, M.D. Obesity is increasingly prevalent
worldwide, and about 40% of Americans meet the diagnostic criteria for
obesity.[1] The goal of weight loss is to reduce the mortality and morbidity risks
associated with obesity. Patients with a body-mass index (BMI) in the range that
defines obesity (>30) have a risk of death that is more than twice that of persons
with a normal BMI.[2] Obesity is also associated with increased risks of
cardiovascular disease, diabetes, and several cancers. A recent study suggests
that being overweight or obese during adolescence is strongly associated with
increased cardiovascular mortality in adulthood.[3] Studies suggest that even a
5% weight loss may reduce the complications associated with obesity.[4] In
September 2016, we presented the case of Ms. Chatham, a 29-year-old woman
with class I obesity (BMI, 32) who leads a fairly sedentary lifestyle, with frequent
reliance on takeout foods and with infrequent physical activity.[5] Readers were
invited to vote on whether to recommend initiating treatment with one of the FDA-
approved drugs for weight loss along with lifestyle modifications or to recommend
only nonpharmacologic therapies and maximizing lifestyle changes. The patient
has no coexisting medical conditions, but her blood pressure is slightly elevated
(144/81 mm Hg). In the past, Ms. Chatham has tried to lose weight using various
diets, each time losing 10 to 15 lb (4.5 to 6.8 kg), but she has never been able to
successfully maintain weight loss. Over 85,000 readers viewed the Clinical
Decisions vignette during the polling period, and 905 readers from 91 countries
voted in the informal poll. The largest group of respondents (366) was from the
United States or Canada, representing nearly 40% of the votes. A large majority
of the readers (80%) voted against prescribing one of the FDA-approved
medications for weight loss and instead recommended maximizing lifestyle
modification and nonpharmacologic therapies first. A substantial proportion of the
64 Journal readers who submitted comments expressed concern about the
absence of efficacy data on long-term follow-up and about the side effects
associated with current FDA-approved medications for weight loss. Some
suggested that simply treating obesity with a prescription medication is
shortsighted and that it is important to uncover patients’ motivations for existing
lifestyle choices and for weight loss. The commenters emphasized the need for a
multifaceted approach to obesity management that includes nutritional and
psychological support, as well as stress management, with the goal of long-
lasting improvement in exercise and eating habits that will lead to weight
reduction and maintenance of a healthier weight. Some commenters, noting the
difficulty of lifestyle changes, felt that pharmacotherapy can be a complementary
and reasonable part of a multidisciplinary treatment plan. Some wrote that
obesity should be managed as a chronic disease is managed and that an inability
to lose weight should not be seen as a disciplinary issue, especially given the
importance of genetic and physiological factors. These commenters argued that
the use of pharmacotherapy as part of the treatment plan to achieve weight loss
should not be stigmatized. Overall, the results of this informal Clinical Decisions
poll indicate that a majority of the respondents think physicians should not initially
recommend the use of an FDA-approved drug as part of a weight-loss strategy,
at least not for a patient such as Ms. Chatham, and that many respondents were
troubled by the current uncertainties about the long-term efficacy and safety of
weight-loss drugs. REFERENCES 1. Flegal KM, Kruzon-Moran D, Carroll MD,
Fryar CD, Ogden CL. Trends in obesity among adults in the United States, 2005
to 2014. JAMA 2016;315:2284-91. 2. Global BMI Mortality Collaboration. Body-
mass index and all-cause mortality: individual-participant-data meta-analysis of
239 prospective studies in four continents. Lancet 2016;388:776-86. 3. Twig G,
Yaniv G, Levine H, et al. Body-mass index in 2.3 million adolescents and
cardiovascular death in adulthood. N Engl J Med 2016;374:2430-40. 4. Kushner
RF, Ryan DH. Assessment and lifestyle management of patients with obesity:
clinical recommendations from systematic reviews. JAMA 2014;312:943-52. 5.
Yeh JS, Kushner RF, Schiff GD. Obesity and management of weight loss. N Engl
J Med 2016;375;1187-9.