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According to CDC data, obesity prevalence in the United States increased 12% over 18 years to reach a robust 42.4% in 2018. The annual medical cost of the condition was estimated at $147 billion — back in 2008.
Obesity is now viewed as a chronic disease in America.
It’s long been understood that obesity can initiate an array of other serious health conditions, including heart disease, type 2 diabetes, and certain types of cancer. In today’s healthcare ecosystem, obesity itself is now regarded as a chronic disease.
There are many ways for internal medicine physicians and nurses to work with their patients to implement and fine-tune medical management of obesity. One of the thought leaders and experts in this ongoing effort is Jonathan Q. Purnell, MD, Professor of Medicine, Medical Director of the Interdisciplinary Weight Management Program, Knight Cardiovascular Institute Preventive Cardiology Group, Oregon Health Sciences University, Division of Cardiovascular Medicine, School of Medicine, Portland.
Dr. Purnell discussed several compelling, key aspects of medical management of obesity in a recent lecture entitled “Medical Management of Obesity.” AudioDigest recorded Dr. Purnell’s insightful talk at the 28th Annual Internal Medicine Review, presented by Oregon Health & Science University School of Medicine, Continuing Professional Development, from April 8-9, 2021. Touching on an array of topics and providing sharp insights, the approximately 30-minute lecture (followed by a 7-minute question-and-answer period) holds value to anyone and everyone interested in understanding more about medical obesity management.
“There are over 200 associated conditions with obesity,” says Dr. Purnell at the outset of his lecture. You also have mechanical conditions; things like osteoarthritis, back pain, sleep apnea. We now view obesity itself as a chronic disease. That means we treat it like other chronic diseases. I hope I can overcome some of the hesitations that primary care doctors have in this space.”
As Dr. Purnell explains, human beings are governed by interactions among three major organ systems — the brain (or the “command center”); the gastrointestinal (GI) system; and adipose tissue (or “sensing organs”). As we consume a meal and begin to digest the food, the nutrient absorption process triggers a pattern of gut hormone secretion. Once the brain realizes we are “full,” the stomach begins to produce the hormone ghrelin. In the words of Dr. Purnell:
“The levels of these fullness hormones continue to rise until you reach a point where your brain says, ‘OK, we’re done. We’re full. We’re satisfied with this particular meal.’”
After fullness is achieved, gut hormone levels begin to gradually fall. As ghrelin levels once again rise over time, we become hungry again. Consuming less than a normal, full meal results in decreased secretion of satiety hormones and decreased suppression of ghrelin. The failure to achieve full satisfaction stimulates food-seeking behavior.
“My point to patients is we don’t count our calories, but our brain knows how much we’re eating based on the changes to the levels of these gut hormones,” says Dr. Purnell in his lecture. “These behaviors are driven by internal biological signals that we can’t will away. We don’t control them. They control us.”
This is where medical treatment strategies for obesity and medical management of weight loss come into play. Medications for weight management that have been approved by the Food and Drug Administration (FDA) include tetrahydrolipstatin; phentermine plus topiramate (Qsymia); bupropion plus naltrexone; and liraglutide. Dr. Purnell chooses to refer to these medications as “appetite control agents,” rather than the traditional nomenclature of “appetite suppressants.”
These medications bind to the receptors in the hypothalamus and “potentiate the fullness signal,” in the words of Dr. Purnell. Satiety is then achieved with fewer calories, and the hunger hormone is dampened between meals.
Dr. Purnell clarifies that patients must meet criteria for medical management of weight loss, also referred to as “pharmacologic weight management.” Those criteria include a Body Mass Index (BMI) of 27 or higher, with weight-related comorbidity, especially hypertension, dyslipidemia, or diabetes mellitus — or a BMI greater than 30, with no comorbidity required.
Dr. Purnell stresses that it’s best to attempt healthy lifestyle changes first, and to continue to emphasize and work on these changes even after obesity medications have been administered. He also cautions that weight loss with these medications is variable, and long-term treatment will be necessary. Effectiveness of the medications typically plateaus when patients weigh from 6-10% below their initial weights.
“Weight loss is variable,” explains Dr. Purnell. “Some people lose the expected amount. Some people don’t lose any weight whatsoever. What I tell patients is, ‘It’s not your fault.’”
Like all medications, medications for weight management come with some contraindications — or factors that render the drug’s administration inadvisable.
When it comes to pharmacologic weight management, Dr. Purnell emphasizes that pregnant women should not take these medications.
Patients who have active heart disease, heart failure, arrhythmias, or untreated hypertension, or are taking monoamine oxidase inhibitors, should not take phentermine, phentermine-topiramate, or bupropion. For such patients, other obesity management avenues should be explored.
Dr. Purnell is a firm believer and passionate advocate for the power and efficacy of medical management of obesity and weight management medications. He also understands some of the hesitancy and caution around this approach to obesity management — and looks forward to serving as an advocate for effective and safe change.
“Still embedded within our relative psyches as practitioners are that weight-loss drugs have a poor safety record,” reasons Dr. Purnell. But this is no different from any other class of drug.
“I hope I can overcome some of the hesitations that primary care doctors have in this space. Anything I can do to help practitioners start to incorporate this into their portfolio of activities, I think that would be great.”
If you’re looking to enhance your knowledge and take your practice to the next level, AudioDigest can serve as a vital, versatile partner. If you found this article and Dr. Purnell’s insights beneficial, we invite you to explore additional AudioDigest content from trusted experts and thought leaders, including these Top 5 CME Lectures in Internal Medicine.
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