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Transcript

Lee Tetreault:

Hello and welcome to frequently asked questions from the session, "What's new in obesity management." Today I'm joined by Dr. Robert Kushner. Doctor, before we start, could you get into some of the key pointers from today's session for our audience? 

Robert F. Kushner: 

Sure, there's three points I wanna get across. The first is that all primary care providers should assess and advise patients with obesity regarding the importance of weight loss, and provide treatment either buy a referral or within the practice itself. The second is that if lifestyle therapy is not effective enough, treatment should be intensified to use an anti-obesity medication if it's indicated. We now have five medications that are FDA-approved for weight loss and long-term weight maintenance. And the third is that obesity should be considered a long-term chronic and often relapsing disease. Patient needs ongoing support and treatment similar to other chronic diseases that we treat every day such as diabetes or hypertension.

Lee Tetreault:

Let's get into some of these frequently asked questions. First, what is the best way to assess patients with obesity? 

Robert F. Kushner: 

Well, the most common thing we use is the BMI or body mass index. The US Preventive Services Task Force recommends that all adults have a BMI measured annually and to follow up thereafter. Obesity is defined as a BMI of 30 or greater. Overweight is 25 to 29.9. But it's important to emphasize that BMI alone does not define the disease of obesity. We also have to assess for obesity-related comorbidities, or the burden of obesity, such as things like diabetes, hypertension, metabolic syndrome, sleep apnea and others. It's also important to measure waist circumference in patients, at least for those with a BMI of less than 35, because we know that upper body segment fat distribution is associated with increased obesity burden.

Lee Tetreault:

What is the best diet for treating obesity? 

Robert F. Kushner: 

The most important factor when it comes to diet is to change the energy balance disregulation. What I mean by that is that you wanna reduce total calories. Obesity is in large part a calorie balance equation, if you wanna simplify it, and you need to reduce total calories. The diets that you actually choose is based on a whole host of other factors that's important to the patient such as practicality, the patient's lifestyle, their preferences for food, the culture in which they live, need for convenience, particularly in our urban environment where we're doing things all the time, as well as their health. In general, I'd say that plant-based diets are associated with longer term cardiovascular health, and probably the best data we have is for the Mediterranean-type diet.

Lee Tetreault:

What is the best exercise for weight loss? 

Robert F. Kushner: 

It's a common question I'm asked. And I think in terms of a movement portfolio, what I mean by that is you have physical activity, which is an umbrella term, and that consists within a continuum. What you wanna talk about are several factors: First, reduce sedentariness. In other words, reduce the amount of time patients are sitting, getting them to move and stand up and be more active. In the middle is activities of daily living. And so having them walk and walk up the escalator, walk to co-worker's desk, take a walk with their dog, and household activities, whether it's doing the lawn or things within the house. At the other end of the spectrum, we talk about exercise which is planned, repetitive, and purposeful. Here we talk in terms of aerobic activity, resistance training, stretching, flexibility, balance and so forth. So overall, we want people moving. And a good goal to shoot for, in the beginning, is 150 to 300 minutes per week of what we call moderately vigorous physical activity, which is equivalent to brisk walking.

Lee Tetreault:

When would you use an anti-obesity medication? 

Robert F. Kushner: 

We now have five anti-obesity medications, they're called AOMs, that's the class, and they've been approved by the FDA for weight loss and maintenance of weight loss. Four of these medications have been approved since 2012. They're indicated by the FDA in a package insert for patients with a BMI of 30 or greater, or patients with a BMI 27 or greater with a comorbidity such as diabetes or hypertension. Now, other factors to consider when thinking about medication include patients who are following lifestyle change but unable to meet their goals, they're struggling to be consistent with lifestyle, and there's no contraindications. And of course, the last factor is cost and patient... It has to be affordable or covered by the insurance. And you wanna use shared decision-making with the patient in order to decide is medication a good idea and, if so, which one? 

Lee Tetreault:

And lastly, doctor, how do the medications work? 

Robert F. Kushner: 

These anti-obesity medications work in different parts of the brain that affect the appetite. By modifying signals in the brain, patients get the benefit of feeling less hungry, more full after a meal, that's called satiation, more content between meals, which is called satiety, have less cravings and, for many patients, less thoughts of food. Now, the effects vary, of course. Not all patients are responsive and not every patient gets all of these appetite-suppressing effects. The bottom line is that the rationale for use of medications is to help patients adhere to a lower calorie diet more consistently in order to achieve more sufficient weight loss and health improvements when they're combined with diet and increased physical activity.

Lee Tetreault:

This is great information, Doctor. Thank you so much for your time today.