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Despite the passage of 15 years, I remember each clinical encounter in which my pediatrician attempted to address my weight — it only happened twice. Each time I was mortified, and I could tell he was hesitant. He would say my labs were fine, that there was no cause for alarm, but that I should watch my weight because I was obese. I would nod my head vigorously to show I acknowledged and understood his advice, trying to move on with as little actual exchange on the subject as possible. Though the experiences of being overweight and obese are unique, multifaceted and countless, I sometimes think back to my own past when I encounter new tools in the field of obesity therapy.
The release of the “Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline” has followed by strong phrasing, including “blueprint,” “first-ever” and “shifts the paradigm.” To the extent that these guidelines break new ground, it is important for researchers, practitioners and patients alike to ask what foundation they lay.
The 2013 guidelines for obesity care released by The Obesity Society, the American Heart Association and the American College of Cardiology are very detailed, but they are noticeably mum on the subject of pharmacotherapy (due to the lack of available evidence and drug options at the time of their drafting); the new guidelines connect that missing puzzle piece.
The new guidelines make 19 recommendations grouped into three categories concerning the “care of a patient who is overweight or obese,” “drugs that cause weight gain and some alternatives” and “off-label use of drugs approved for other indications for chronic obesity management.” The new guidelines also follow the push to “treat obesity first,” a treatment paradigm that trades the existing practice of initially addressing comorbidities and risk factors for addressing the barriers to weight loss first.
This document thus answers many lingering questions related to the clinical management of obesity, but it should also raise new questions for the practicing physician. Whenever new tools are made available to address obesity, we’re reminded that no set of guidelines, no intervention, stands alone when facing an incomprehensibly complex issue. The following questions can help facilitate the thoughtful and sustainable translation of these guidelines.
1. How can I address weight in a sensitive way?
Among the unfortunate revelations of the obesity stigma research is that even medical professionals harbor bias against patients with obesity. Many involved in the obesity community have taken some preliminary steps to combat bias, such as the campaign pushing “People-First Language for Obesity.” Physicians who will potentially treat patients with obesity must be more proactive still in practicing guidelines with minimal bias. This starts with creating a comfortable context with which to address the issue. To this end, a group of physicians in Canada have adapted the classic 5 A’s (ask, assess, advise, agree and assist) for obesity counseling.
2. In what ways will I support or facilitate lifestyle change?
The clinical practice guideline makes several notes reinforcing the importance of lifestyle intervention. The first recommendation states that “diet, exercise, and behavioral modification [should] be included in all obesity management approaches.”
The catch-22 of obesity pharmacotherapy is that it is both a response to the failure of lifestyle change even as it depends on lifestyle change. In addition to building a custom plan, one-on-one with patients who have likely tried many strategies, a physician may consider linking lifestyle change to community-based care and social services. Some physicians may speak with their patients about the Diabetes Prevention Program or similar group programs. Others may consult local directories of resources for patients facing hardship (New York City in particular has a model electronic tool for doing just this, called Health Information Tool for Empowerment).
3. Is this a sustainable lifelong treatment?
As obesity is increasingly recognized as a chronic disease, its treatment options are held up to the standard of long-term maintenance. Drugs are a treatment category that presents special considerations in this context. First, they are and seem likely to remain expensive for most patients. An annual cost that ranges between $4,000 and $6,000 and lacks sufficient insurance coverage can be difficult to sustain over time.
Beyond the hefty financial burden of drug therapies, patients who take them may not have previously thought of themselves as having a condition in need of treatment. To then recognize their excess weight as a condition in need of pharmacotherapy is jarring — it’s a cultural shift. The medical anthropologist Janis Jenkins wrote about this shifting orientation at length, arguing that patients realize a pharmaceutical self when they’re prescribed drugs and must reorient their life in light of medication. Either way, drug therapy represents a big decision in the life of a patient, one that cannot be scrutinized too closely.
4. What is my plan for assessing side effects and maintenance?
Many patients will remember keenly that past drug therapies in the area of obesity care were taken off the shelves for their ultimately unacceptable risk profile. To this end, recommendations 1.3 to 1.5, as well as recommendation 1.8, make several remarks about the safety, tolerability and efficacy of drugs. Even where the guidelines can make moves to give a prescribing physician confidence, that does not immediately transfer over to the patient. Given the unique prescribing context of obesity, physicians may find themselves needing to go above and beyond to work with their patients on setting a drug monitoring plan into action.
Even as the new clinical practice guideline closes gaps and answers open questions, they themselves introduce a conversation about the sensitive and dynamic world of obesity therapy. I’m fortunate that self-guided lifestyle change is a therapy that worked for me — in a sense, that made the limpness of my clinical encounters more forgivable. With greater resources and attention going toward obesity therapy today, patients and their doctors alike have the a lot more to be grateful for.
Rajiv Narayan recently completed an MSc in Medical Anthropology at the University of Oxford as a Rotary Ambassadorial Scholar. He entered the obesity field after losing 100 lbs. himself.
