Obesity Management in Adults PDF (2023)

Clinical Review & Education JAMA | Review Obesity Management in Adults A Review Arielle Elmaleh-Sachs, MD, MS; Jessica L. Schwartz, MD, MHS; Carolyn T. Bramante, MD, MPH; Jacinda M. Nicklas, MD, MPH; Kimberly A. G...

Clinical Review & Education JAMA | Review Obesity Management in Adults A Review Arielle Elmaleh-Sachs, MD, MS; Jessica L. Schwartz, MD, MHS; Carolyn T. Bramante, MD, MPH; Jacinda M. Nicklas, MD, MPH; Kimberly A. Gudzune, MD, MPH; Melanie Jay, MD, MS Multimedia IMPORTANCE Obesity affects approximately 42% of US adults and is associated with CME at jamacmelookup.com increased rates of type 2 diabetes, hypertension, cardiovascular disease, sleep disorders, osteoarthritis, and premature death. OBSERVATIONS A body mass index (BMI) of 25 or greater is commonly used to define overweight, and a BMI of 30 or greater to define obesity, with lower thresholds for Asian populations (BMI ⱖ25-27.5), although use of BMI alone is not recommended to determine individual risk. Individuals with obesity have higher rates of incident cardiovascular disease. In men with a BMI of 30 to 39, cardiovascular event rates are 20.21 per 1000 person-years compared with 13.72 per 1000 person-years in men with a normal BMI. In women with a BMI of 30 to 39.9, cardiovascular event rates are 9.97 per 1000 person-years compared with 6.37 per 1000 person-years in women with a normal BMI. Among people with obesity, 5% to 10% weight loss improves systolic blood pressure by about 3 mm Hg for those with hypertension, and may decrease hemoglobin A1c by 0.6% to 1% for those with type 2 diabetes. Evidence-based obesity treatment includes interventions addressing 5 major categories: behavioral interventions, nutrition, physical activity, pharmacotherapy, and metabolic/bariatric procedures. Comprehensive obesity care plans combine appropriate interventions for individual patients. Multicomponent behavioral interventions, ideally consisting of at least 14 sessions in 6 months to promote lifestyle changes, including components such as weight self-monitoring, dietary and physical activity counseling, and problem solving, often produce 5% to 10% weight loss, although weight regain occurs in 25% or more of participants at 2-year follow-up. Effective nutritional approaches focus on reducing total caloric intake and dietary strategies based on patient preferences. Physical activity without calorie reduction typically causes less weight loss (2-3 kg) but is important for weight-loss maintenance. Commonly prescribed medications such as antidepressants (eg, mirtazapine, amitriptyline) and antihyperglycemics such as glyburide or insulin cause weight gain, and clinicians should review and consider alternatives. Antiobesity medications are recommended for nonpregnant patients with obesity or overweight and weight-related comorbidities in conjunction with lifestyle modifications. Six medications are currently approved by the US Food and Drug Administration for long-term use: glucagon-like peptide receptor 1 (GLP-1) agonists (semaglutide and liraglutide only), tirzepatide (a glucose-dependent insulinotropic polypeptide/GLP-1 agonist), phentermine-topiramate, naltrexone-bupropion, and orlistat. Of these, tirzepatide has the greatest effect, with mean weight loss of 21% at 72 weeks. Endoscopic procedures (ie, intragastric balloon and endoscopic sleeve gastroplasty) can attain 10% to 13% weight loss at 6 months. Weight loss from metabolic and bariatric surgeries (ie, laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass) ranges from 25% to 30% at 12 months. Maintaining long-term weight loss is difficult, and clinical guidelines support the use of long-term antiobesity medications when weight maintenance is inadequate with lifestyle interventions alone. CONCLUSION AND RELEVANCE Obesity affects approximately 42% of adults in the US. Behavioral interventions can attain approximately 5% to 10% weight loss, GLP-1 agonists and Author Affiliations: Author affiliations are listed at the end of this glucose-dependent insulinotropic polypeptide/GLP-1 receptor agonists can attain article. approximately 8% to 21% weight loss, and bariatric surgery can attain approximately 25% to Corresponding Author: Melanie 30% weight loss. Comprehensive, evidence-based obesity treatment combines behavioral Jay, MD, MS, Departments of interventions, nutrition, physical activity, pharmacotherapy, and metabolic/bariatric Medicine and Population Health, procedures as appropriate for individual patients. New York University Grossman School of Medicine, 550 First Ave, New York, NY 10016 (melanie.jay@ nyulangone.org). Section Editor: Mary McGrae JAMA. 2023;330(20):2000-2015. doi:10.1001/jama.2023.19897 McDermott, MD, Deputy Editor. 2000 (Reprinted) jama.com © 2023 American Medical Association. All rights reserved. Downloaded from jamanetwork.com by Universidad Nacional Autonoma de Mexico (UNAM) user on 12/04/2023  Review of Obesity Management in Adults Review Clinical Review & Education O besity, currently defined as a body mass index (BMI) of 30 or greater, affects 800 million people worldwide.1 In Risk Factors the United States, approximately 42% of adults have obesity,2 and obesity-related costs are estimated at $173 billion Obesity reflects a chronic energy imbalance, with greater calorie con- annually.3 Obesity is a chronic disease defined by excess adiposity sumption than energy expenditure,18 and is influenced by multiple with structural and functional consequences resulting in factors. Genetic variants are implicated in its development.19 Most increased risk of comorbidities and premature mortality.4,5 Obe- forms of obesity have polygenic risk factors with several variants sity is often associated with stigma, which impairs quality of life strongly associated with BMI, while obesity due to a single gene vari- and increases morbidity.6 Obesity bias contributes to decreased ant is rare.19 The environment influences the relationship between use of preventive cancer screenings among patients with obesity, genetics and obesity risk.19 Adverse workplace, school, social, and particularly in women. 7 Weight loss improves glucose, lipids, home environments, known as “obesogenic environments,” affect blood pressure, and obesity-related comorbidities,4,5,8 and clini- physical and social structures.20 For example, greater availability of cians can offer multiple effective obesity treatments. 9-11 This fast-food restaurants, poor neighborhood walkability, and per- Review summarizes current evidence regarding the pathophysiol- ceived safety risks can limit physical activity and healthy food ogy, diagnosis, and treatment of obesity. options.20 There is a bidirectional association between depression and obesity, wherein each diagnosis is associated with increased risk of developing the other.21 Additional risks include insufficient sleep and low socioeconomic status, in part mediated by chronic stress Methods and food insecurity, which are commonly experienced by racial and We reviewed 9 clinical practice guidelines from relevant medical ethnic minority populations.22 associations published in the last 10 years.4-6,9-14 We then con- ducted a PubMed search on March 1, 2023, which identified 2418 obesity-related systematic reviews and meta-analyses published Pathophysiology of Obesity since 2018. We performed 3 additional PubMed searches on March 6, 2023, to identify systematic reviews of antiobesity Influenced by genetic expression, energy homeostasis is deter- medications published since 2018 (127 articles), clinical practice mined by feedback between circulating neuropeptide hormones and guidelines for obesity published since 2018 (135 articles), and ran- the central nervous system.19,23 The gut-brain axis responds to pe- domized clinical trials (RCTs) published since 2021 on glucagon- ripheral signals from the gastrointestinal tract, adipose tissue, and like peptide 1 (GLP-1) and glucose-dependent insulinotropic circulating hormones to stimulate or inhibit central neurons based polypeptide/GLP-1 receptor agonists to identify studies of newer on satiety or hunger.24 Dysregulation of this system develops in obe- medications (210 articles). We reviewed high-quality studies ref- sity, often leading to increased hunger and decreased satiety.18 erenced in these articles as well as policy guidelines released dur- Hormones involved in this process include leptin and ghrelin.18 Ad- ing the writing of this article. A total of 126 articles were selected ditionally, hormone response and metabolic adaptation promote for this Review, consisting of 26 RCTs, 29 meta-analyses/ weight regain.18 systematic reviews, 14 longitudinal/population-based studies, 15 Obesity increases rates of comorbid conditions through patho- clinical practice guidelines, 4 policy guidelines, 2 cross-sectional physiologic and mechanical changes related to excess adiposity studies, 2 study/intervention descriptions, and 34 narrative and increased weight.23,24 Related conditions include asthma, type reviews. Highest-quality articles and those most relevant to gen- 2 diabetes, hypertension, obstructive sleep apnea, osteoarthritis, eral medical practice were prioritized for inclusion. and cardiovascular disease (CVD).4,5 Compared with normal BMI, obesity is associated with higher rates of incident CVD events, eg, in a pooled cohort of adults aged 40 to 59 years with 856 523 person-years of follow-up, cardiovascular event rates were 20.21 Epidemiology per 1000 person-years in men with a BMI of 30 to 39.9 compared The prevalence of obesity worldwide increased between 1975 with 13.72 per 1000 person-years in men with a normal BMI.25 and 2014 from 3.2% to 10.8% in men and from 6.4% to 14.9% in Cardiovascular event rates were 9.97 per 1000 person-years in women.15 By 2025, it is anticipated that 18% of men and 21% women with a BMI of 30 to 39.9 compared with 6.37 per 1000 of women worldwide will have obesity. 15 The prevalence of person-years in women with a normal BMI.25 Even among patients obesity in the US is higher: 17.4% of non-Hispanic Asian (22.4% with obesity without other CVD risk factors, the long-term inci- using Asian-specific cutoffs 16 ), 49.6% of non-Hispanic Black, dence of CVD is increased compared with people without 44.8% of Hispanic, and 42.2% of non-Hispanic White adults have obesity.26 Weight-related cardiometabolic abnormalities occur obesity.2 It is anticipated that by 2030, 48.9% of US adults will due to excess visceral adipose tissue (and possibly an impaired have obesity and that racial differences in rates of obesity will in- ability to deposit fat into the peripheral adipose tissue such as crease.17 The World Health Organization Acceleration Plan to Stop the gluteofemoral fat compartment), which secretes hormones Obesity, adopted in 2022, outlines multisectoral policies, includ- and proinflammatory cytokines, leading to low-grade systemic ing taxes on sugar-sweetened beverages and subsidies to pro- inflammation.23,24,27 Lipid deposition into adipose tissue and mote healthy diets, school nutrition reforms, and reductions in occurrence of adiposity leads to anatomical changes such as physical inactivity, with the goal of attaining a major reduction increased pharyngeal soft tissue, contributing to obstructive sleep in obesity by 2030.1 apnea or mechanical joint load that results in osteoarthritis.23 jama.com (Reprinted) JAMA November 28, 2023 Volume 330, Number 20 2001 © 2023 American Medical Association. All rights reserved. Downloaded from jamanetwork.com by Universidad Nacional Autonoma de Mexico (UNAM) user on 12/04/2023  Clinical Review & Education Review Review of Obesity Management in Adults Table 1. Evidence-Based Screening Recommendations for Weight-Related Comorbidities4,6,14 Comorbiditiesa Screening method/diagnostic criteria Abbreviations: HDL-C, high-density lipoprotein-cholesterol; Asthma/respiratory disease History, physical examination; spirometry as indicated LDL-C, low-density Diabetes Fasting plasma glucose ≥126 mg/dL; hemoglobin A1c ≥6.5%; 2-h oral lipoprotein-cholesterol. glucose tolerance test SI conversions: To convert total, HDL-, Dyslipidemia Lipid panel that includes triglycerides, HDL-C, LDL-C, total cholesterol, LDL-, and non-HDL cholesterol to and non–HDL-C millimoles per liter, multiply by 0.0259; Gastroesophageal reflux disease History; endoscopy as indicated to convert triglycerides to millimoles Hypertension Sitting blood pressure ≥130/80 mm Hg per liter, multiply by 0.0113. a Metabolic syndrome Three or more of the following: waist circumference ≥88 cm for women, The Association of Clinical ≥102 cm for men; triglycerides ≥150 mg/dL; fasting plasma glucose Endocrinologists and the American ≥100 mg/dL; blood pressure ≥130/85 mm Hg; HDL-C