Elsevier

The Lancet

Volume 387, Issue 10031, 7–13 May 2016, Pages 1947-1956
The Lancet

Seminar
Management of obesity

https://doi.org/10.1016/S0140-6736(16)00271-3Get rights and content

Summary

A modern approach to obesity acknowledges the multifactorial determinants of weight gain and the health benefits to be derived from weight loss. Foundational to any weight loss effort is lifestyle change, diet, and increased physical activity. The approach should be a high quality diet to which patients will adhere accompanied by an exercise prescription describing frequency, intensity, type, and time with a minimum of 150 min moderate weekly activity. For patients who struggle with weight loss and who would receive health benefit from weight loss, management of medications that are contributing to weight gain and use of approved medications for chronic weight management along with lifestyle changes are appropriate. Medications approved in the USA or European Union are orlistat, naltrexone/bupropion, and liraglutide; in the USA, lorcaserin and phentermine/topiramate are also available. Surgical management (gastric banding, sleeve gastrectomy, and Roux-en Y gastric bypass) can produce remarkable health improvement and reduce mortality for patients with severe obesity.

Introduction

In the past 50 years, obesity has become an international public health issue that affects the quality of life, increases the risk of illness, and raises health-care costs in countries in all parts of the world (appendix).1, 2, 3, 4, 5, 6

Measurement of obesity in these surveys1, 2, 3, 4, 5, 6 is done with the body-mass index (BMI; weight in kg/height in m2), which has a good correlation with body fat.7 The BMI has the advantage of simplicity in epidemiological studies, but it has deficiencies because it does not distinguish between fat and lean body mass.8 Thus, BMI should be considered as a screening measurement rather than a diagnostic method. Additional measurements to complement the BMI and should include waist circumference (or waist-to-height ratio).9, 10 Both variables are strong predictors of health risk.9, 10 The physician should take ethnicity into consideration when assessing the waist circumference of a particular patient.11 In addition to measures of central adiposity, blood pressure, glucose, and lipids (HDL and triglycerides) should also be measured.

Obesity management is expensive12, 13 and, along with diabetes, obesity is a disease that needs to be defused.14 Medical costs rise progressively as BMI increases15 and are expected to continue to rise in the next 15 years.16, 17 Obesity is second only to depression in its cost to employers.18

Obesity has a multifactorial nature resulting from genetic, epigenetic, physiological, behavioural, sociocultural, and environmental factors that lead to an imbalance between energy intake and expenditure during an extended time period. The importance of less sleep, endocrine disruptors—such as some chemicals in food packaging and foods—increased time in climate-controlled areas, cessation of smoking, weight gain that is associated with some medications, older parental age at birth, and intrauterine and intergenerational effects have been reported as contributors to the obesity epidemic.19, 20

Obesity shortens life span21 and affects the function of many organ systems21, 22, 23 (appendix). Mortality results from several diseases that are associated with obesity, including diabetes, chronic kidney disease, gastrointestinal disease, and cardiovascular disease and maintaining weight loss is often difficult or unsuccessful.24, 25

Section snippets

Management of the patients with obesity

The rising prevalence of obesity worldwide calls for preventive strategies to defuse the future health and economic costs of this problem Economic and technological changes in the environment have driven the obesity epidemic,26 and many studies have tested strategies in schools, work-sites, and the community that might prevent the rise of BMI, but so far these efforts have had little effect,27, 28 and the evidence for use of effective economic policies to prevent obesity remains limited.26

When

Lifestyle changes

The cornerstone for treatment of a patient with obesity in the USA, UK, and Europe, and many other countries is a comprehensive, or multicomponent lifestyle intervention.29, 30, 32, 35 The term comprehensive refers to simultaneous implementation of three strategies: lifestyle or behavioural training, dietary change to reduce energy intake, and an increase in physical activity. The evidence supporting the efficacy of lifestyle intervention or behavioural modification is supported, partly, by

Diets for weight loss

Several considerations enter into selecting a diet for weight loss. It must have less energy than is required for daily maintenance29, 43, 44 and be one to which the patient will adhere and possibly provide other health benefits. A reduction of energy by 500 kcal/day below energy requirements or by using a dietary plan that has 1200–1500 kcal/day for women or 1500–1800 kcal/day for men (increased by a further 300 kcal/day for each sex if weight exceeds 150 kg) will accomplish the first goal. In

Physical activity

Increased physical activity is an essential component of comprehensive lifestyle intervention for obesity management. The recommendations in US and UK guidelines typically prescribe gradually increasing aerobic physical activity (such as brisk walking) to reach a goal of more than 150 min/week (equal to >30 min/day, for at least 5 days each week).29, 32, 54 This has benefits for general health that are independent of weight loss.55 Meta-analysis32, 56 of trials indicated that this results in an

Pharmacotherapy

A systematic review and clinical guidance29 sponsored by the Endocrine Society promotes the concept that, for patients with obesity, medicating for chronic diseases should be with a weight centric focus. Many medications in use for common chronic diseases produce weight gain, and others are associated with weight loss, albeit those medications do not have an obesity indication. Whenever possible, patients with obesity should avoid medications associated with gain and use weight neutral

Surgical procedures to treat obesity

Bariatric surgery has rapidly become used as a treatment option for severe obesity, particularly since the advent of lower risk laparoscopic procedures, with nearly half a million procedures done worldwide in 2013.89 A range of procedures are now well established, which result in varying degrees of weight loss; each procedure has its own risks and benefits which need to be considered carefully with each patient (table 3).90

Long term studies of outcomes after bariatric surgery have generally

Controversies

As with other areas of medicine, not all issues have been resolved and several controversies are still being debated. Should the topic of obesity be a strong focus of undergraduate medical education or should it be taught mainly at the post graduate level?106 Weight bias is commonly reported in medical students and experienced doctors to stigmatise patients.107 This stigma might be reduced if the complexities of obesity were introduced earlier. This stigma might also partly explain why obesity

Search strategy and selection criteria

We searched for original articles and reviews published between Jan 1, 1990, and Aug 31, 2015, focusing on obesity management in PubMed and MEDLINE using the following search terms (or combination of terms): “obesity”, “weight loss”, “management”, “treatment”, “guidelines”, “recommendations”, “costs”, “outcomes”, “comorbidity or comorbidities”, “body composition”, “life-style intervention”, “physical activity”, “exercise”, “pharmacotherapy”, “medication”, “anti-obesity drugs”, “bariatric

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