Bariatric Endocrinology: Obesity, Adiposity and Adiposopathy
October 2021
Volume 10, Issue 3

Chapter 1: Multifactorial Approaches to Treatment

American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity

Endocr Pract. 2015;3:22

Adipose cells

The accumulation of fat mass is a multifactorial process. The approach to its treatment is also multifactorial. No single intervention will be effective over time, and treatment needs to be structured the same way as for any other chronic diseases. It is essential that each patient understands that weight management is for life.

The primary focus needs to be on behavior modification to achieve decreased caloric intake and increased caloric expenditure. We still recommend avoiding the terms “diet” and “exercise” and using meal planning, healthy eating, good nutrition and daily physical activity instead.

A thorough evaluation for obstacles to achieve effective behavior modification must be done. Circumstances and underlying diseases that develop and progress over time have to be identified and adequately managed. Many of the complications of weight gain develop into causes of further weight gain. Therefore, a very important first step is to evaluate a patient for these obstacles and address them. They include:

  • Socio-economic strain, social isolation and poor support structures
  • Depression
  • Low self-esteem, body image disturbance and social stigmatization
  • Sleep apnea
  • Hypoventilation syndrome
  • Congestive heart failure
  • Joint degeneration and pain
  • Male hypogonadism
  • Hyperinsulinemia
  • Immobility, gait instability and deconditioning
  • Pharmacotherapy for other conditions

Patients should be reassessed for these obstacles if they reaccumulate fat mass, or if they are ineffective in doing so to begin with.

Hunger and satiety are central nervous system signals that become the major regulators of energy balance over time. The central nervous systems that regulate hunger and satiety take neural and humoral signals from the periphery. The efferent limbs are also neural and humoral. With afferent signals that originate from cells throughout the abdominal cavity and efferent signals that direct back to them, the approach to treatment has broadened.

In addition to pharmacotherapy with CNS targets, there are now procedures directed to decrease caloric intake by restricting intake or modifying intestinal and visceral function to decrease absorption. A review of all medications used by the patient is needed on a regular basis, and an effort must be made to remove agents that promote weight gain. Substitution with medications that promote weight loss is necessary.

The stepped approach to patients relies on ongoing support to have good nutrition and adequate physical activity indefinitely. A team approach that involves dieticians, coaches, clinical psychologists and other specialists is optimal for patients to meet their treatment goals. If a single institution is not able to provide this level of support, then it must levy these resources from the community.

Patient care continues with pharmacotherapy or non-invasive procedures. Pharmacotherapy should be used as we do with other chronic diseases, starting with monotherapy and adding to this over time, progressing to combination therapy. Since no patented medications for weight management are approved for use with other medications for weight management, there must be a discussion of off-label use when any two of them are used together. The medical record must have documentation of this discussion and a reflection that the patient wishes to proceed. Non-invasive procedures may be put in place at any time, in addition to pharmacotherapy.

The third-party payer structure is a major obstacle for effective implementation and continuation of patient care. Since each patented medication has on its label that it is not recommended for use in combination with any other weight loss products, third-party payers will not cover beyond one medication. And they are frequently prone to stop coverage under the responsiveness criteria on the labels. Patients must be educated about this and each encouraged to advocate for change.

Over time, more aggressive procedures may be considered for patients whose disease is truly refractory to medical management. The invasive procedures range from minimally invasive surgery and endoscopic procedures to the well-established bariatric procedures.

This update will have additional sections to review current and upcoming pharmacotherapy for weight management, current non-invasive procedures, current invasive procedures (endoscopic and other) and a review on the economics of medical care for our patients.

Commentary

Next Article:
Chapter 2: Pharmacotherapy as a First-Line Treatment
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