(Overweight, Obesity and Severe Obesity)
Physician-supervised weight-loss programs provide treatment in a clinical setting with a licensed healthcare professional, such as a medical doctor, nurse, nurse practitioner, physician assistant, registered dietitian and/or a psychologist. These programs typically offer services such as nutrition and physical activity counseling and behavioral therapy.
The cost to participate in a physician-supervised weight-loss program varies depending upon the services offered. Health insurance companies may cover some or all of your treatment particularly if you have weight-related health conditions such as heart disease, hypertension or diabetes.
The Initial Consult:
A physician, physician assistant or nurse practitioner specializing in obesity treatment provides the initial consultation. The initial consult involves a focused medical evaluation for diseases related to obesity and causative factors, along with a physical examination. In addition, the medical professional will obtain a weight history, which includes past diet attempts, and may conduct a thorough psychological history.
Many patients come to the clinic with undiagnosed diabetes, high cholesterol, thyroid disorders, abnormal liver tests or obstructive sleep apnea. Additional testing may be recommended depending upon the medical history and physical findings.
Overall, the physician management of obesity may include:
- Behavior Modifications (diet and exercise)
- Pre-packaged Meal Replacement Plans
- Pharmacotherapy (weight-loss medications)
Diet and exercise are often the front-line of defense when it comes to weight-loss and most individuals affected by obesity do struggle with this; however, diet and exercise should be the first place for you to start. Regardless of treatment choice, lifestyle modification through diet and exercise is essential to the success of any weight-loss program.
It seems simple right? We just need to control the calories that we consume. Unfortunately, deprivation from foods we are used to eating is difficult to accept by our bodies and minds. In addition, when dieting, the body reacts very quickly by activating compensatory mechanisms that increase appetite and slow metabolism. This makes dieting even harder. As a result, the weight-loss achieved by diet alone is about 5 percent of total body weight.
Dieting today is not what “dieting” was 10 or 15 years ago. With the integration of technology, you can easily log your daily caloric intake and keep track of what you eat. There’s even a mobile app that allows you to take a picture of your food and it will tell you how many calories are in it!
Physical activity is an important addition to diet, as it boosts metabolism and increases weight-loss. Physical activity is particularly important in helping to maintain weight-loss long-term.
There are many tools available to help you find the right exercise for you. From smartphone apps to full-service fitness centers equipped with all the bells and whistles, you can easily make exercise a part of your daily routine. Start slow by simply going for a walk each day and build up to more intense exercises such as jogging, swimming, biking, weight lifting and more.
Pre-packaged Meal Replacement Plans
Pre-packaged meal replacement plans are a medically supervised weight management program that utilizes meal replacement products and behavior change counseling to help patients reach and maintain their weight-loss goals. These programs work to help patients transition to self-prepared meals and offer patient education and support. Some of the available programs on the market today include OPTIFAST®, Health Management Resources (HMR), Advanced Health System (AHS), New Direction (Robard Corporation) and Medi-fast.
How do they work?
Individuals who are interested in starting a supervised weight management program must do so through a healthcare professional. Most programs will list participating providers in the area on their Web site.
A medically supervised weight management program consists of various phases individualized to the needs of the person seeking weight loss. The phases include some type of a meal replacement phase to achieve initial weight-loss and eventually transitions to a phase of self-prepared foods for long term weight management. In addition, patients have the guidance of a team of healthcare professionals, access to group or individual counseling, as well as other support options. Programs may vary slightly.
Individual results will vary, but patients may lose as much as 50 pounds or more in 18-24 weeks.
As with any meal replacement program, there are concerns regarding the ability of participants to be able to re-adjust to eating healthy outside the program once completed. Additionally, insurance coverage varies depending on provider; therefore, individuals interested in the program should contact their provider to understand whether all or a portion of the program fees are covered. Individuals may consider it expensive if it is not covered by insurance.
Medical Weight Management:
Note: None of the obesity medications discussed in this brochure should be taken while pregnant or attempting to become pregnant. One medication, Qsymia®, has specific FDA warning label information around the use of birth control due as to a birth defect risk. If you have any questions regarding these medications, please contact a healthcare provider.
Who Qualifies for Obesity Medications?
Although everyone is hopeful for a fast and easy way to lose weight, nothing has been shown to replace a prudent, calorie-controlled diet along with behavior modification and an increase in physical activity as a cornerstone for all obesity treatments. Other options, such as the use of weight-loss medications, can be considered if weight-loss levels out at a still unacceptable range or if medical problems are not adequately controlled.
The next tool that can be used to achieve weight-loss and health improvement is medication. Medical Weight Management may be offered to individuals affected by obesity who have failed to achieve weight-loss through diet and exercise alone.
Currently there are several medications that are approved by the FDA for weight-loss:
- phentermine products (Adipex-P® or Suprenza®)*
- orlistat (Xenical® or alli®)†
- lorcaserin HCI (Belviq®)†
- naltrexone HCI AND bupropion HCI (CONTRAVE®)†
- phentermine- topiramate ER (Qsymia®)†
- liraglutide injection (Saxenda®)†
- *Approved for short term use
- †Approved for chronic(long term) use
Let’s take a closer look at each of these medications and learn how they work:
Phentermine (Adipex-P® or Suprenza®)
Phentermine is a medication available by prescription that works on chemicals in the brain to decrease your appetite. It also has a mild stimulant component that adds extra energy. Phentermine is a pill that is taken once a day in the morning time. Tolerance to this medication can develop, so it is often used for only several months at a time. Common side effects are dry mouth and sleeplessness.
The average weight-loss is 4-5 percent of your weight after one-year. In a 200 pound person, this means about 10 pounds of weight-loss.
Due to its stimulant effect, a person’s blood pressure and heart rate may increase when on this medication; therefore, you must be monitored closely by a physician who is experienced in prescribing this medication. It cannot be used in patients with some heart conditions (such as poorly controlled blood pressure), glaucoma (increased pressure in your eye), stroke or overactive thyroid. There is some concern for abuse, but this is minimal if the medication is appropriately used as directed by a healthcare professional.
Orlistat (Xenical® or alli®)
How does it work?
The medication alli® is a lower potency of the prescription drug Xenical® (orlistat). It is the only FDA-approved weight-loss medication that is available over-the-counter and available at a higher dose with a prescription. It is a capsule that is usually taken three times per day before a meal that contains dietary fat. It works by decreasing the amount of fat your body absorbs. This means that only 2/3 of the calories that you take in from fat will be absorbed. The other 1/3 of the calories gets carried away in the digestion tract as stool. The company that makes this drug (GlaxoSmithKline Consumer Healthcare) also offers a Web site with education and support tools for users at www.myalli.com.
The average weight-loss is about 5 percent of your weight after one year. In a person who weighs 200 pounds, this would mean 10 pounds of weight-loss.
It does not work well for people who are already on a low-fat diet since their calories from fat are already low.
Individuals using alli® on a regular basis should take a daily multivitamin as there is potential for deficiency in some vitamins. One of the advantages of alli® is that its side effects are limited to the gastrointestinal system. Common side effects are cramps, gas, stool leakage, oily spotting and gas with discharge that improve with a lower fat diet.
Lorcaserin HCI (Belviq®)
How does it work?
Lorcaserin HCI was approved in June 2012 by the FDA and became commercially available in June 2013. It works by helping you feel full while eating less, and it works on the chemicals in your brain to help decrease your appetite.
In individuals who took the medication for one-year, it has been shown to have an average of 7 percent weight-loss. In a 200 pound person, this would mean a 14 pound weight-loss. Blood sugar, cholesterol and blood pressure levels have also been shown to improve.
The most common side effects are headache, dizziness, fatigue, dry mouth, upper respiratory tract infection and nausea.
Naltrexone HCI AND Bupropion HCI (CONTRAVE®)
CONTRAVE®, approved in 2014 by the FDA, is a combination of two medications that have been approved for other medical problems. Naltrexone is a medication used for the treatment of narcotic and alcohol dependency. Bupropion is used as an antidepressant and for helping people stop smoking. When used in combination, these two medications work together in the brain to decrease appetite and control eating.
Among individuals who took the medication for one year, 65 percent of the study subjects lost at least 5 percent of their body weight. In a 200 pound person, this would mean a 10 pound weight-loss. Also, 39 percent lost at least 10 percent of their body weight. In a 200 pound person, this would mean a 20 pound weight-loss. Improvements in bad cholesterol, triglycerides and good cholesterol were also seen.
The common side effects are nausea, constipation, headache, dry mouth, vomiting and dizziness.
Phentermine-Topiramate ER (Qsymia®)
This combination medication was approved by the FDA in July 2012. Topiramate is a medication used in migraine prevention as well as seizure prophylaxis. It was found that a common side effect of this medication was weight-loss. Phentermine, as described in this brochure, helps to increase your energy and decrease your appetite.
Among individuals who took the highest does of Qsymia® (15 mg phentermine and 92 mg of topiramate ER) for one-year, they achieved an average of 14.4 percent weight-loss. In a 200 pound person, a 14.4 percent weight-loss would mean a loss of 29 pounds. Cholesterol levels have also been shown to improve.
The most common side effects were dry mouth, constipation and pins-and-needle feeling in extremities. Qsymia® should NOT be used in women of childbearing age who are not using at least one reliable form of contraception. Topiramate ER, a component of Qsymia®, has been known to cause birth defects.
Liraglutide injection (Saxenda®)
Liraglutide, approved in 2014 by the FDA, is an injectable medication that increases our natural production of insulin, which is needed to regulate the levels of sugar in the blood. It decreases the production of a hormone that opposes insulin called glucagon. It also slows down the emptying of the stomach. Lastly, it works in the brain to reduce the amount of food consumed. As such, it has been used for the management of diabetes for the last few years.
In four trials consisting of more than 5,000 individuals, participants received 3mg of liraglutide daily. The outcomes showed that among individuals who took the medication for one year, 73 percent of the study subjects lost at least 5 percent of their body weight. In a 200 pound person, this would mean a 10 pound weight-loss. Also, 41 percent lost at least 10 percent of their body weight. In a 200 pound person, this would mean a 20 pound weight-loss.
The most common side effects are nausea, vomiting, diarrhea, and constipation.
Patients are given the opportunity to revisit a topic or obtain more information on an area of interest during follow-up visits. The frequency of and interval between follow-up visits is determined on a patient-by-patient basis. Frequent visits (every 3 to 4 weeks) are encouraged until initial weight-loss goals (5 to 10 percent of body weight) are achieved. At that point, less frequent visits are typically scheduled as needed for individual patients. However, since obesity is considered a chronic life-long problem for many individuals, periodic continual follow-up is recommended.
The best weight-loss results are achieved with a comprehensive program involving physicians, dietitians and behavioral specialists providing individual guidance and treatment. Most importantly, the major weight-loss benefit is the improvement of diseases caused by obesity. Although weight-loss achieved by diet, exercise and medications seems modest, research has shown that weight-loss as low as 5 percent of initial body weight can lead to favorable improvements in blood pressure, cholesterol, glucose levels and insulin sensitivity. The risk of developing heart disease is reduced the most in patients who have impaired glucose tolerance, type 2 diabetes or high blood pressure. Moreover, this beneficial effect can be carried on for many years after losing weight.