American College of Physicians: Internal Medicine — Doctors for Adults ®


Doctors don’t have to dread discussing dieting

From the November/December ACP Internist, copyright 2012 by the American College of Physicians

By Stacey Butterfield

Obesity researcher Sara Bleich, PhD, knows firsthand the frustration of counseling someone about weight loss. Her best friend has struggled with her weight for a long time.

“She would always ask me, ‘What are some tricks for losing weight?’ I would always say some version of ‘Eat less, exercise more,’” said Dr. Bleich. “Ten years later, she said to me, ‘I think I know why I’m not losing weight.’ I lean in; what’s she going to say? She said, ‘I think I’m eating too much and not exercising enough.’”

Photo by Hemera

Photo by Hemera

The prescription for weight loss may be simple, but as anyone who has ever tried it knows, the execution is not. And the prescription options are also about to get a little more complicated, with the recent FDA approval of two new drugs for weight loss.

Whether these new options will significantly affect Americans’ ability to execute their weight loss plans is a matter of debate among experts. They agree, however, that general internists hold much of the responsibility for determining the use of these drugs and generally facilitating their overweight and obese patients’ weight loss.

“Many internists are not discussing obesity and weight loss with their obese patients,” said Kimberly Gudzune, MD, assistant professor at the Johns Hopkins School of Medicine and an internist at the Johns Hopkins Digestive Weight Loss Center in Maryland. “Or if they are, patients are not remembering the message.”

She estimated that 20% to 40% of obese patients report receiving any weight loss counseling from their primary care physician.

Physicians’ reluctance is understandable for several reasons.

“It’s hard for physicians to actually tell a patient that they’re obese or overweight, because the reaction from the patient can be hard for them to deal with,” said Dr. Bleich, an assistant professor at the Johns Hopkins School of Public Health in Baltimore.

And, although obesity is one of the most common health risks facing Americans, weight loss is not a topic physicians are taught a lot about.

“Only something like a quarter of medical schools even have a course in nutrition. The average physician knows less about nutrition than a slightly overweight housewife who reads up on it,” said Richard Atkinson, MD, emeritus professor of medicine and nutritional sciences at the University of Wisconsin, Madison.

Finally, weight loss care is hindered by the usual bugaboo of primary care practice—time. “Teaching someone how to not eat when they’re hungry, how to exercise when it’s not comfortable, is going to be a lot bigger task than can be done in eight minutes,” Dr. Atkinson said.

The good news is that there are things a physician can do with those eight minutes that appear to make a difference in their patients’ weight. “Patients who are told they need to lose weight report more confidence, report more actively trying to do so,” said Dr. Bleich.

Some additional actions can increase the impact of that advice, although each expert had a slightly different perspective on the best course of action. “The challenge about weight loss and weight management is that there really isn’t a good gold standard,” Dr. Bleich acknowledged.

She favors giving patients a few quick tips: Avoid sugary beverages, moderate portion size and drink water (“People’s cues are really messed up and they think they’re hungry when they’re actually thirsty,” she said). Then, patients who are interested should be referred to a nutritionist for additional counseling.

It would be ideal if every overweight patient could see a nutritionist, but insurance coverage and clinician shortages make that unrealistic, according to Dr. Atkinson.

“If you took all the primary care physicians in the country, and all their nurse practitioners and all the dieticians, there simply aren’t enough to treat two-thirds of the American population,” he said.

That’s why he recommends sending patients to an evidence-based commercial weight loss program.

“[Physicians] need to become comfortable with a high-quality commercial weight loss program in their area, one that is doing reliable work and has reliable programs,” Dr. Atkinson said, citing Weight Watchers and Jenny Craig as two examples.

Dr. Gudzune added, “A non-profit weight loss program such as Take Off Pounds Sensibly (TOPS) may be a lower-cost option for patients.”

Cost is an important consideration in weight loss treatment, agreed Dr. Bleich.

“If you are a low-income patient, living in a food ‘desert’ area with little access to fresh fruits and vegetables, and your physician says to you, ‘You need to start cooking fruits and vegetables,’ that’s in one ear and out the other,” she said.

One physician-led program recently found an innovative solution to that specific problem (see sidebar on this page). But cost is only going to become a bigger issue if pharmaceuticals become a more prominent part of the weight loss treatment picture.

“We’re going to need obesity drugs. Obesity is a chronic, lifelong, incurable disease,” said Dr. Atkinson. “We’re in the position with obesity now that we were in with hypertension when I was in medical school all the years ago. We had lousy drugs that didn’t work very well and had side effects.”

Yes, even though he sees pharmaceutical treatment as the most likely solution to obesity, he views the current options as lousy. “Relatively lousy, but they are a start,” he qualified.

A start is about what patients will get from lorcaserin hydrochloride (Belviq). It was approved earlier this year for adults with a body mass index (BMI) of 30 kg/m2 or greater or those with a BMI of 27 kg/m2 or greater who have at least one weight-related condition such as hypertension, type 2 diabetes or dyslipidemia.

In clinical trials, the drug, a serotonin 2C receptor agonist, helped patients lose 3% of their body weight after adjustment for placebo. “That is not meaningful and additionally the drug is not completely safe,” said David Gortler, PharmD, a former medical officer on the FDA’s lipids and obesity team and current associate professor of pharmacology at The Georgetown School of Medicine in Washington, D.C.

“That drug approval was kind of a shocker to me,” added Dr. Gortler. “It didn’t even meet the FDA’s own white paper requirements for efficacy.”

“I think lorcaserin by itself is doomed,” said Dr. Atkinson. “It’s not going to sell huge amounts of product, because unless it’s used with another drug, it doesn’t cause a big enough weight loss.”

He did see some promise if the FDA were to allow the combination of lorcaserin with other drugs, such as phentermine.

“It’s almost impossible to name a chronic disease, if you’ve got a bad case, that is not treated with more than one drug. Yet the medical establishment thinks we need to have a single magic bullet [for obesity],” Dr. Atkinson said.

Dr. Gortler agreed about the necessity of combining therapies in order to achieve significant weight loss using pharmaceuticals. “When you’re dealing with satiety, you’re dealing with hundreds and perhaps thousands of different neuroendocrine markers. As soon as you inhibit one, you’ve got many more taking over,” he said.

The other new drug recently approved by the FDA does combine medications. Qsymia is made up of topiramate and phentermine. It helped patients achieve significant weight loss in trials. “Weight loss after one year was between 14% and 15% at the highest dosing regimen. This is quite remarkable,” said Dr. Gortler.

There’s a catch, though. “Efficacy is not the issue; safety is the issue,” he said, noting that patients taking topiramate have reported problems with global confusion. “In some cases, there were people who complained they were driving home and suddenly couldn’t remember where they lived,” Dr. Gortler said.

However, Dr. Atkinson predicted that may be less of an issue with the new drug. “The combination will probably cause somewhat fewer side effects than topiramate alone,” he said.

It won’t remove the risk of birth defects, however. Women of reproductive age, who would likely be major consumers of the medication, should be tested for pregnancy monthly, according to the Qsymia drug labeling. Patients should also receive ongoing monitoring for metabolic acidosis, hypokalemia and increased creatinine.

Qsymia became available for sale in September. Belviq is expected to become available sometime next year. Both drugs come with recommendations to monitor for changes in mood and symptoms of congestive heart failure, and the Belviq label additionally suggests complete blood counts, because leukopenia and anemia have been reported.

All of these issues should be discussed with patients considering a weight loss drug.

“Patients need to understand how these medications work, the amount of weight loss that they can reasonably expect, as well as the side effects and risks of each medication,” said Dr. Gudzune. “I typically spend at least 10 minutes discussing this information with patients to determine how a weight loss medication might fit into their weight loss plan.”

The medications might be most useful for patients who have already begun to execute a plan, with less than complete success. “It’s so hard in the beginning. You’re going to the gym five days a week, you’re modifying your diet, and you’re not seeing any movement on the scale,” said Dr. Bleich.

“If you combine that with a weight loss drug which shows relatively quicker weight loss, psychologically that can really help a person stay on the right track, because they’re actually seeing that they’re making a difference,” she added.

David Katz, MD, FACP, founder of the Yale-Griffin Prevention Research Center in Derby, Conn., summed up many of the experts’ perspective. “Mostly [the drugs] may be an alternative to surgery for those who need a ‘jump start’ and are then willing to transition to a lifestyle-based approach,” he said. “They are both rather poor drugs.”

How soon we’ll have better drugs is uncertain. “This is not going to be something we are going to be able to easily cure with pharmacology. In our lifetime, there’s not going to be a single pill that’s going to cure obesity on a long-term basis,” said Dr. Gortler.

Dr. Atkinson offered a little more hope. “There are a number of different companies trying to work on the gut hormones. The problem is ... they have to be injected. People like to inject themselves like they like a hole in the head,” he said. But, he added, “I’m hoping that at some point we’re going to figure out a way to get cocktails of these gut hormones.”

In the meantime, internists can help their overweight and obese patients by raising the issue and offering them all the currently available resources. “The primary care physician is going to have to marshal his or her resources to help the obese patient,” Dr. Atkinson said.



Rx = fresh fruit and veggies

Pediatrician Shikha Anand, MD, always followed recommended practices in treating in her overweight and obese patients. “I was continually recommending increased fruit and vegetable consumption according to dietary guidelines and repeatedly my families would tell me, ‘OK, but we don’t have the money, it doesn’t exist in our neighborhood, you’re asking us to do the impossible.’”

Working with a nonprofit called Wholesome Wave, Dr. Anand now does something to eliminate those hurdles. Patients at some community health clinics in the Boston area (Dr. Anand practices at Boston Medical Center) get “prescriptions” for fresh fruits and vegetables.

The prescription is a voucher, which can be cashed in for fresh food at local farmers’ markets. It’s distributed to any family with an overweight or obese child or a pregnant woman, after a consultation with a physician and nutritionist. There is no income limit on the program, but it’s targeted at underserved communities.

The voucher is equal to one dollar per household member per day, or $128 a month for a family of four.

“We recognized that eating patterns are household,” said Dr. Anand. “If we just gave the prescription for a child, either that small amount of fruits and vegetables will be watered down over the whole family, or healthy eating wouldn’t be normalized within the family.”

So far, the program seems to have some success in normalizing health eating. “We know that 38.1% of our patients either maintain or decrease their body mass index over a four-month period,” Dr. Anand said.

Controlled research on the effects of the program is planned, but already the anecdotes have been positive. “We have heard anecdotally from our market partners that customers continue to return even when the voucher dollars don’t exist,” she said.

The program obviously also benefits farmers’ market vendors and may provide additional good to the community. “We’re able to influence the sustainability of those markets in underserved communities that don’t always thrive. In some cases, we’ve seen expanded hours or vendors, largely because of this program,” Dr. Anand said. “It’s improving access both for those who are using the vouchers and the rest of the community.”

Participating physicians have appreciated the opportunity to connect their patients with the food they should be eating. “They can really help promote health, not just treat disease, which I don’t think modern medicine is always structured to help us do that,” Dr. Anand said.

Dr. Anand hopes to soon spread that opportunity to more clinics and physicians, as the financials of the privately funded program allow. “The goal is to expand to hospital-based ambulatory clinics and other ambulatory settings that serve the underserved,” she said.



Diet may improve vasomotor symptoms in postmenopausal women

Eating a healthy diet may help improve vasomotor symptoms in postmenopausal women, according to a recent study.

Researchers set out to determine whether a diet that reduced fat intake and increased intake of fruit, vegetables and whole grains, along with resulting weight loss, would improve vasomotor symptoms of menopause, such as night sweats and hot flashes. They examined data from participants in the Women’s Health Initiative Dietary Modification Trial who were not taking hormone replacement therapy. Women in the intervention group followed a low-fat diet (20% of energy from fat) with high intake of fruit and vegetables (five servings a day) and whole grains (six servings a day) and received group sessions with a nutritionist or dietitian, while women in the control group received written information on healthy diets. The study results were published in the September Menopause.

Overall, 17,743 women from 50 to 79 years of age were included in the study. At baseline, 74% reported no hot flashes, 19% reported mild hot flashes, 6% reported moderate hot flashes, and 1% reported severe hot flashes. In addition, 73% reported no night sweats while 20% reported mild night sweats, 6% reported moderate night sweats, and 1% reported severe night sweats.

Multivariate-adjusted analyses that were also adjusted for intervention and for weight change found that women in the dietary intervention group who had vasomotor symptoms at baseline were significantly more likely to report symptom cessation than those assigned to the control group (odds ratio [OR], 1.14 [95% CI, 1.01 to 1.28]). Those who had symptoms at baseline but lost at least 10 pounds (OR, 1.23 [95% CI, 1.05 to 1.46]) or at least 10% of their body weight (OR, 1.56 [95% CI, 1.21 to 2.02]) by year 1 were also significantly more likely to report symptom cessation than those who maintained their baseline weight.

When the authors looked at the combined effect of dietary modification and weight loss, they found that women who lost at least 10% of their body weight via the intervention had a better chance of eliminating vasomotor symptoms than women in the control arm who lost the same amount, although the difference was not significant (ORs, 1.89 [95% CI, 1.39 to 2.57] vs. 1.40 [95% CI, 0.92 to 2.13]). An association was seen between large weight loss (i.e., over 22 pounds) and elimination of moderate to severe symptoms, but this association was not seen for dietary changes.

The authors noted that they didn’t use objective measures of symptoms and didn’t measure frequency, among other limitations. However, they concluded that the type of diet examined in this trial appeared to alleviate vasomotor symptoms in postmenopausal women, “over and above the effect of weight change.” Their findings support the idea that weight loss and changes in diet could be used as alternatives to hormone replacement therapy for vasomotor symptom relief in this population, they said.

This item originally appeared in an e-newsletter provided every Wednesday by ACP Internist. To receive ACP InternistWeekly, call Customer Service at 800-543-1546, ext. 2600, or direct at 215-351-2600; e-mail us; or subscribe online.


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