Along with medications, patients must be treated with a team approach that involves nutrition counseling and exercise, Further, it is important that patients understand the treatment plan involves lifestyle changes and not just going on a diet, he said. 

“The team approach to obesity should be the same as the team approach to diabetes. Just like we take care of diabetes, we should take care of obesity,” Dr. Gonzalez-Campoy said in an interview with Endocrinology Advisor.

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Barriers Remain

Physicians face many barriers to effectively managing their obese patients, including a lack of reimbursement and many other issues, Dr. Gonzalez-Campoy said. Some physicians are not comfortable with the newer medications and how to best manage the side effects associated with them. 

“They never learned how to use drugs for obesity and they are not used to it. There have been drugs removed from market for obesity and some that never made approval because of safety concerns,” said Dr. Gonzalez-Campoy. “Physicians are just not jumping onboard as we would have hoped. Doctors have to have time to get comfortable treating obesity as a chronic disease, which is just going to take time.”

One very real concern, however, is the safety of combining various medications and having patients take the medications over a number of years and decades.

Currently, there are no evidence-based data to support the long-term use of these medications. Nevertheless, short-term data have shown these agents to be safe and effective, and clinicians must weigh the risks along with other cardiovascular (CV) risks when deciding whether to use these therapies in the long term.

W. Timothy Garvey, MD, Professor of Medicine and Chair of the Department of Nutrition Sciences at the University of Alabama at Birmingham, said endocrinologists and primary care physicians need to rethink how they view overweight and obese patients.

“If someone fails one of these medications, we have additional options to treat them with. It is the same principle as with antibiotics. If one antibiotic doesn’t work, you can try another,” Dr. Garvey told Endocrinology Advisor.

“We surely need long-term studies. We have 2-year data on these medicines, and we know they achieve weight loss for that long, but we don’t have data for longer than 2 years. It is the same way with antihypertensive medications.”

He expects that over the next 24 months, evidence will emerge based on clinician experiences that may point to optimal prescribing strategies. Over time, a rational, evidence-based approach will be developed to more effectively guide pharmacotherapy for chronic use, according to Dr. Garvey.

Moving Beyond Just BMI

Dr. Garvey and his colleagues have validated a cardiometabolic disease staging system (CMDS) that may be able to discriminate a wide range of risk for diabetes and CV mortality independent of BMI for overweight patients.1

He said obesity can exacerbate insulin resistance and promote cardiometabolic disease progression. However, he said the relationship is very complex when it comes to BMI and cardiometabolic disease progression. Insulin resistance may exist independent of BMI, according to Dr. Garvey.

Studies show fat distribution and waist circumference may be significant factors to consider when managing obese patients. Dr. Garvey said the CMDS can be used as a risk assessment tool to guide the medical management for the prevention and treatment of cardiometabolic disease in obese patients.