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KirsiPietiläinen

Conservative (Non-Surgical) Treatment of Obesity

Essentials

  • An individual obesity treatment plan should be made together with the patient. See articles Raising the subject of obesity, and assessment of obesity Raising the Subject of Obesity, and Assessment of Obesity and Motivational interviewing The Role of Motivational Interviewing in Changing Lifestyles and in Treatment.
  • In the treatment of obesity, it is important to avoid banal and self-evident advice, such as “eat less, increase your physical activity”.
  • Lifestyle counselling is based on four foundation pillars (food, physical activity, sleep and mental skills), and it can be provided either individually, in groups, remotely or in digital form.
  • In addition to lifestyle counselling, obesity can be treated with medication, a very low calorie diet (VLCD) or bariatric surgery.
  • Permanent weight loss of 5-10% is useful for the treatment of most diseases associated with obesity.

Choice of treatment approaches Strategies for Sustaining Weight Loss, Surgery for Morbid Obesity, Interventions in the Treatment and Prevention of Obesity

Mini-intervention Motivational Interviewing in the Treatment of Chronic Diseases and Behavioural Problems, Health Gains from the Treatment of Obesity

  • Elements of brief counselling / mini-intervention
    • Assessment of obesity: weight, height, body mass index (BMI), waist circumference as appropriate, any associated diseases
      • Note the sensitivity of weighing. The data is entered in the patient record.
    • Raising the subject of obesity and habits at the correct time, using a patient-centred approach and showing respect Raising the Subject of Obesity, and Assessment of Obesity
    • Concrete self-care plan
    • Presentation of locally available means of supporting weight reduction and weight management
  • The aim of a mini-intervention is to motivate the patient to treat obesity themselves, which can be helpful in itself.
    • Nevertheless, patients should always also have access to other treatment options.
  • Obesity and its treatment should be discussed with the patient in a positive and encouraging manner, utilizing a patient-centred working method. This entails the background and life situation of each patient being taken into account and avoidance of top-down types of advice.
  • The patient should be informed about various methods of weight management and weight reduction, as well as their practical implementation.
  • An agreement should be made on the first concrete changes that would help in weight management.
  • The patient should be given printed information about weight reduction or guided to get further information from relevant sources.
  • Patients should be informed that they can get in touch if they need further support for weight management. They should be asked about the progress of weight reduction during any subsequent appointments.

Basic obesity treatment, or lifestyle guidance (lifestyle counselling)Weight Loss and Health-Related Quality of Life, Low Glycaemic Index or Low Glycaemic Load Diets for Overweight and Obesity

Essentials

  • Obesity should primarily be treated by lifestyle guidance. As a coaching approach is used for this, it can also be called lifestyle counselling.
  • Treatment concentrates on the four pillars of habits supporting weight management: dietary habits, physical activity, sleep and mental skills.
  • A coaching approach is used instead of top-down instructions and guidance.
  • Encouraging the patient in a positive tone is essential.
  • The goal is to find new, flexible living habits. Changes that are too limiting are rarely permanent.
  • Changes can be carried out gradually: one can start with 1-2 changes and try more later on.

Core contents of lifestyle guidance

  • Assessment of the patient's situation
  • Setting individual goals for change
  • Committing the patient to lifestyle changes and reinforcing their motivation
  • Teaching dietary habits supporting weight management
  • Reinforcing eating management
  • Increasing physical activity and reducing sedentary life
  • Ensuring sufficient sleep
  • Teaching mental skills, such as emotional processing, management of daily life, time and stress, self-compassion
  • Weight monitoring based on individual assessment

Dietary habits

  • Weight management is best supported by dietary habits that are realistic even in the long term, considering the patient's health and personal preferences.
  • Eating that supports weight reduction and permanent weight management
    • The primary aim is to find a satiating diet, reducing the intake of food low in nutrients and ensuring sufficient intake of various nutrients.

Supporting eating management and satiety

  • Regular meal rhythm
    • 3 main meals (breakfast, lunch, dinner) and 1-2 snacks
  • Protein
    • The estimated protein requirement is no less than 80 g/day, roughly 1 g / kg weight per day in people weighing less than 120 kg. For people heavier than this, see local sources for special recommendations.
  • Increased fibre intake
    • 500-800 g of vegetables and fruit including berries per day

Other means to support satiety and eating management

  • Mindful eating
    • Observing why eating begins. Craving or hunger?
    • Concentration on eating; not doing anything else while eating (no newspapers/magazines, phone, TV)
    • Recognizing satiety
    • Slowing down eating, chewing
  • Recognizing situations and factors involving risks to eating management
  • Planning grocery shopping and meals
  • Reducing temptations (avoidance of keeping products suitable for snacking at home and to hand)
  • Meals with sufficient quantity of food but low in energy (to avoid “hunger deficit”)

Reducing energy density and food and drink with low nutrient content

  • Reducing portion sizes of food with high energy content
  • Following the plate model, for example
  • Liquid dairy products should be fat-free, other drinks mainly calorie-free (water, sugar-free soft drinks).
  • Reduction of alcohol consumption

Ensuring a varied diet

  • Varied, healthy everyday food, and healthy snacks
  • Preferably
    • Vegetables or fruit including berries
    • Wholegrain cereal
    • Fish, legumes
    • Nuts, almonds, seeds
    • Low-fat dairy products
  • Restrict the use of
    • Red meat, processed meat
    • Food high in hard fat, salt or sugar
    • Alcohol

Physical activity

  • From a health point of view, the best type of physical activity is one that you like and can do regularly.
  • Physical inactivity in everyday life should be recognized, and the amount of sedentary time should be decreased.
  • Daily physical activity, i.e. increased muscle work during daily activities, should be particularly encouraged (climbing up stairs, commute to work, etc.)
  • The target is at least half an hour on most days of the week of a type of exercise that the patient is able and willing to perform.
  • To maintain and improve physical fitness, 150-300 minutes a week of aerobic training (such as brisk walking), and strength training or movement control exercises twice a week are recommended for all adults.

Sleep

  • Regular sleep rhythm and sufficient sleep
    • Adults are recommended 7-9 hours of sleep at night.
    • The need for sleep varies individually.
    • If you wake up in the morning feeling alert and stay alert during the day without taking naps, you have had enough sleep at night.
    • Factors affecting sleep quality (alcohol, coffee, working late and using the phone) should be avoided.
  • Any sleep-associated disorders such as sleep apnoea should be investigated.

Mental skills

  • Management of daily life and time as regards eating, physical activity and sleep
  • Stress management
  • Association between emotions and eating
  • Flexible attitude to food
  • Positive body image
  • Self-compassion

Weight monitoring

  • The primary aim and measure of change should be a changed lifestyle, not “chasing every kilogramme or centimetre”.
  • The aim should always be to achieve the most permanent result possible.
  • Regular weight monitoring promotes weight management and provides information on the effectiveness and need of lifestyle changes.
    • If there is binge eating or if weight monitoring is compulsive or affects a flexible attitude to eating and eating management, weight monitoring cannot be recommended.
  • Implementation and frequency of weight monitoring should be planned individually.
  • The patient should always be weighed in similar clothes (such as light indoor clothing) at the same time of the day, preferably in the morning.
  • An acceptable rate of weight reduction is approximately 0.5 kg/week. A less rapid rate of weight loss is also possible.
  • A permanent weight reduction of 5-10% benefits the treatment of many obesity-related diseases.
  • The change can also be assessed by
    • Monitoring how the patient is feeling
    • Monitoring changes to experienced functional capacity (e.g. finding it easier to put on shoes or to climb stairs, and improved alertness)
    • Measuring waist circumference
    • Monitoring the length of the patient's belt
    • Monitoring changes to clothing size.
  • Weight monitoring is important after weight loss because there is a considerable tendency to regain weight. This is due to changes occurring in the secretion of intestinal hormones increasing hunger and decreasing satiety, and to decreased energy consumption after weight loss. Early detection of weight regain facilitates remodification of habits to support weight management.

Drug therapy Guar Gum for Weight Reduction, Ephedra and Ephedrine for Weight Loss, Chitosan for Obesity, Chromium Picolinate Supplementation for Overweight or Obese Adults, Rimonabant for Weight Reduction, Orlistat and Sibutramine for Obesity and Overweight

  • Medication can be tried to support lifestyle changes, if the basic treatment of obesity alone has not yielded a sufficient result.
  • When prescribing an anti-obesity drug, the patient should always also be provided with guidance relating to lifestyle changes, and the realization of the changes should be followed up.
  • Use of medication increasing satiety often facilitates appetite control and thus dietary changes considerably. The patient should be informed about this benefit, and systematically planned dietary changes should then be implemented.
  • An anti-obesity drug can be considered for those with BMI over 30 (or over 27 in the presence of diabetes or other disease that warrants weight loss).
  • Obesity is a chronic disease, and anti-obesity medication (with lifestyle guidance) should therefore be planned to be used in the long term. However, for the time being, there is no sufficient scientific evidence for optimum duration of treatment or for whether the medication can be planned to be taken for the rest of life, as is done with medication for other chronic diseases.
  • The patient should be informed that drug treatment of obesity is planned to last for several years. On stopping medication, a gradual reversal of weight loss is usually seen. If medication is withdrawn, this should be done in a controlled fashion, lowering the dose slowly and paying special attention to weight monitoring and to lifestyle changes that are aimed at prevention of weight regain.
  • Discontinuation of drug treatment should be considered if the patient has not lost a significant amount of weight within 3-4 months (at least 5% of the initial weight).
    • If, however, the patient says they benefit from the medication in other ways (increased satiety, decreased cravings), continued medication can be considered even in the absence of significant weight loss.
    • Weight regain may be possible after withdrawing what is considered ineffective medication, if the patient's dietary habits change without noticing or if increased satiety (that was not necessarily recognized) is lost.
  • The following anti-obesity drugs are available: naltrexone/bupropion, liraglutide, semaglutide, tirzepatide, orlistat, phentermine/topiramate.
    • With the exception of orlistat, all these reduce appetite. This effect should be utilized by combining the drug therapy with comprehensive lifestyle counselling.
    • Country-specific differences in the drugs' availability and their reimbursement may apply.

Naltrexone/bupropion

  • The effect of a combination product of naltrexone (8 mg) and bupropion (90 mg) (Mysimba® ) comes about primarily through reduction of appetite. Bupropion decreases the reuptake of dopamine and noradrenaline, and naltrexone, an opioid-receptor antagonist, is considered to inhibit the otherwise activated feedback system and thus to potentiate the effect of bupropion on energy balance.
  • The initial dose of the naltrexone/bupropion combination is 1 tablet per day. The dose should be increased gradually, every 1-2 weeks, for example, up to 2 tablets twice daily.
  • The most common adverse effects include nausea, vomiting, constipation, dry mouth, sleeping problems, dizziness and tremor. Blood pressure and heart rate may increase.
  • Due to sleeplessness as an adverse effect, the evening dose should be taken early in the evening.
  • If adverse effects occur, the dose should be increased more slowly.
  • Not to be used by patients with hepatic or renal insufficiency, with uncontrolled hypertension, bipolar disorder or a history of seizures.
  • A separate checklist may be available by local pharmaceutical authorities.
  • In one-year follow-up the weight loss in the medication group was 6.1-6.4%, significantly higher than with lifestyle treatment alone (placebo group 1.2-1.3%).

Liraglutide 3.0 mg

  • Liraglutide is an appetite-reducing GLP-1 (glucagon-like peptide 1) analogue injected once daily. Liraglutide 3.0 mg (Saxenda® ) is indicated in the treatment of obesity. Liraglutide stimulates insulin secretion from the pancreas, depending on the blood glucose level, and reduces glucose production in the liver, which is why it is also used for type 2 diabetes at doses of 1.2-1.8 mg once daily (Victoza® ).
  • Due to liraglutide's mechanism of action, blood glucose levels decrease more than with weight loss alone. Liraglutide 3.0 mg prevents the development of type 2 diabetes.
  • Administration is by subcutaneous injection (in the morning).
  • The initial dose is 0.6 mg once daily. The dose should be increased in increments of 0.6 mg at 1-2-week intervals, for example, up to a dose of 3.0 mg once daily.
  • If nausea, severe anorexia or other adverse effects appear, the dose should be increased more slowly.
  • The most common adverse effects include nausea, vomiting, heartburn, diarrhoea, constipation, abdominal pain and digestive disturbances. Hypoglycaemia may occur in combination with other hypoglycaemia-inducing drugs.
  • In one-year follow-up the weight loss in the medication group was 8.0%, significantly higher than by lifestyle treatment alone (placebo group 2.6%).

Semaglutide 2.4 mg

  • Semaglutide is an appetite-reducing GLP-1 (glucagon-like peptide 1) analogue injected once a week. Semaglutide 2.4 mg (Wegovy® ) is indicated in the treatment of obesity.
  • Semaglutide stimulates insulin secretion from the pancreas, depending on the blood glucose level, and reduces glucose production in the liver, which is why it is also used for type 2 diabetes.
  • Ozempic® is a semaglutide product injected once weekly for the treatment of diabetes (dosage strengths 0.25, 0.5, 1.0 mg). Rybelsus® is an oral semaglutide taken daily for the treatment of diabetes (dosage strengths 3, 7, 14 mg).
  • Due to semaglutide's mechanism of action, blood glucose concentrations decrease more than with weight loss alone.
  • The drug is given as subcutaneous injections once weekly.
  • The initial dose is 0.25 mg/week. The dose can be increased once a month (0.5, 1.0, 1.7, 2.4 mg).
  • If nausea, severe anorexia or other adverse effects appear, the dose should be increased more slowly.
  • The most common adverse effects include nausea, vomiting, heartburn, diarrhoea, constipation, abdominal pain and digestive disturbances. Hypoglycaemia may occur in combination with other hypoglycaemia-inducing drugs.
  • In 68-week studies, the weight loss in the medication group was 14.9%, significantly higher than with lifestyle treatment alone (placebo group 2.4%).
  • There is significant weight regain after withdrawal.
  • Semaglutide 2.4 mg has been shown to decrease cardiovascular endpoints.

Tirzepatide

  • Tirzepatide (Mounjaro® ) is an appetite-reducing dual GLP-1 (glucagon-like peptide 1) and GIP (glucose-dependent insulinotropic polypeptide) hormone analogue. In addition, tirzepatide lowers blood glucose levels.
  • Tirzepatide is indicated in the treatment of both obesity and type 2 diabetes.
  • The drug is given as subcutaneous injections once weekly.
  • The initial dose is 2.5 mg/week. The dose can be increased in increments of 2.5 mg once a month, as necessary. The recommended maintenance doses are 5, 10 or 15 mg/week.
  • If nausea, severe anorexia or other adverse effects appear, the dose should be increased more slowly.
  • The most common adverse effects include nausea, vomiting, heartburn, diarrhoea, constipation, abdominal pain and dyspepsia. Hypoglycaemia may occur in combination with other hypoglycaemia-inducing drugs.
  • In 72-week studies, the weight loss in the medication group was 22.5%, significantly higher than with lifestyle treatment alone (placebo group 2.4%).

Phentermine/topiramate

  • The combination of phentermine and topiramate (Qsiva® ) is an appetite-reducing tablet product. Phentermine stimulates the release of noradrenaline.
    • Topiramate has many sites of action, such as GABA-A receptors.
  • The combination of phentermine and topiramate is taken once daily in the morning. The initial dose is 3.75 mg/23 mg for 14 days. The recommended maintenance dose is 7.5 mg/46 mg. Higher doses, 11.25 mg/69 mg or 15 mg/92 mg, should be used only after separate consideration.
  • Due to the risk of seizures, if high-dose treatment (15 mg/92 mg) is to be withdrawn, this should be done gradually by taking a dose every other day for at least 1 week before complete withdrawal.
  • Phentermine/topiramate may have adverse foetal effects. Before introducing the drug to any woman capable of becoming pregnant, a pregnancy test must be carried out and the patient must be advised to use extremely effective contraception. Phentermine/topiramate may affect the efficacy of oral ethinyl oestradiol contraceptives.
  • The most common adverse effects are nausea, dry mouth, paraesthesias, constipation, headaches, dizziness, sleeplessness, palpitations, mental and cognitive dysfunction.
  • A separate checklist may be available by local pharmaceutical authorities.
  • If adverse effects occur, the dose should be increased more slowly.
  • In one-year follow-up the weight loss in the medication group was, depending on the dose, 5.1-10.9% (placebo group 1.2-1.6%).
  • Phentermine/topiramate has marketing authorization in, for instance, the Nordic countries and in Poland.

Orlistat Effect of Weight-Reducing Drugs in Hypertensive Patients

  • Orlistat is a lipase inhibitor which acts on the digestive tract. It partially reduces the absorption of dietary fat. Orlistat is not absorbed into the bloodstream.
  • Due to the mode of action of orlistat, the concentration of LDL cholesterol will decrease more than it would with weight reduction alone.
  • Orlistat is used in association with main meals, three times daily.
  • Orlistat 120 mg is a prescription drug, whereas orlistat 60 mg is in some countries available as an over-the-counter drug.
  • When using the drug, the aim is to limit the proportion of dietary energy intake from fat to no more than 30%. Only low-fat snacks should be consumed. The patient should receive sufficient dietary counselling regarding low-fat diet, since otherwise the adverse effects will prevent the use of the drug.
  • Common adverse effects include fatty or oily stools, faecal urgency and oily leakage from the rectum (> 1/10 users), which are associated with the consumption of too fatty foods.
  • Orlistat may reduce the absorption of fat-soluble vitamins from the intestinal tract. In long-term orlistat use it is recommended to use a multivitamin preparation as well (not to be taken at the same time with the orlistat capsule, but usually in the evening before going to bed).
  • In two-year follow-up a dose of 60 mg three times daily (weight loss 7% of initial weight) and 120 mg three times daily (weight loss 8%) reduced weight significantly more than lifestyle treatment alone (placebo group 4.5%).
  • As orlistat may impair the absorption of drugs such as thyroid medication, antiepileptics and amiodarone, response to such treatment should be checked when using orlistat.

Very low calorie diet (VLCD)

  • The daily dose of VLCD products provides about 800 kcal energy, 30-60 g carbohydrates, about 75 g protein, at least 12 g essential fatty acids, and the required vitamins and trace elements.
    • To ensure sufficient protein intake and to prevent excess muscle wasting, patients should also eat, besides the dietary product, 10-60 g protein from low-calorie high-protein food. The need for additional protein should be defined individually by weight; see below.

Schedule

  • The diet consists of commercial formulas available in pharmacies or elsewhere that fulfil the VLCD criteria.
  • The diet should be used according to instructions; for most products 5 (women) or 6 (men) sachets for one day. Every day additionally 500 g of low-carbohydrate vegetables and additional protein so as to make the total protein intake about 1 g / kg weight per day in patients weighing less than 120 kg. For people weighing more, see local recommendations.
  • The diet should be followed for 8-12 consecutive weeks, for example.
  • The diet should be discontinued earlier if a BMI of 25 is reached or if the diet causes adverse effects.
  • During the diet, the patient should be monitored at about 2-week intervals and in the weight management phase at 2-4-week intervals. The frequency should be adjusted on an individual basis and, if resources allow, the monitoring may take place more frequently.
  • The rate of weight reduction is about 1.5-2 kg/week.
  • It is important to provide instructions for the long-term transfer to a normal diet and to follow up the patient to prevent weight regain. For example, if the VLCD consists of 5 packs/day, the consumption during the first week of withdrawal is a breakfast + 4 packs/day, during the second week a breakfast, lunch + 3 packs/day and so on. In this manner the gradual discontinuation of VLCD takes about 5-6 weeks.
  • After this, the programme should include a planned weight management phase (preferably > 6 months), during which the patient remains monitored by health care services. When planning permanent lifestyle changes, take into account the increased hunger, decreased satiety and reduced energy need after weight loss (approximately 500 kcal per 15 kg lost).
  • In order to prevent the regaining of weight, the patient should be informed about what actions to take if weight starts to increase. In such a situation one may, for instance, start using an anti-obesity drug that increases satiety, restart partial use of VLCD sachets for a period or contemplate eating and exercise habits that may help in preventing weight gain.
  • Daily weighing is useful during withdrawal from VLCD to prevent weight regain.
  • The patient should be offered the possibility of getting in touch again if there are problems in maintaining the weight.
  • VLCD alone does not provide permanent results. VLCD should not be used in health care as an exclusive treatment without organized follow-up to support weight management.

Contraindications to a VLCD

  • Type 1 diabetes
  • BMI below 25 kg/m2
  • Age below 18 yrs
  • Pregnancy, breast-feeding
  • Severe disease, such as unstable angina pectoris, cerebrovascular disorder, significant kidney or liver disease or severe infection
  • Eating disorder, risk of triggering binge eating disorder
  • A VLCD should be considered with reserve, and starting such a diet should be carefully considered, if the patient is aged over 65 years or has gout or gallstones.

Changes to medication before starting a VLCD

  • In patients with type 2 diabetes, mealtime insulin should be stopped completely, basal insulin at least halved, and the insulin dose thereafter adjusted according to blood glucose measurements.
  • Sulphonylurea and glinide (prandial glucose regulator) medications should be stopped before starting VLCD.
  • SGLT2 inhibitors should be stopped before starting VLCD (risk of dehydration and ketoacidosis).
  • GLP-1 analogues should be stopped before starting VLCD, but continuing their use in the weight management phase may be considered since they may reduce appetite and hence prevent weight gain after VLCD.
  • Metformin dose should probably be reduced in order to prevent nausea and to protect the kidneys, particularly if the dose is 3 g/day.
  • DPP-4 inhibitors do not require dose reduction before the diet, but reduction often becomes relevant as the weight decreases.
  • It is possible that medications have to be started again after VLCD (based on blood glucose measuring).
  • Antihypertensive drugs should be continued; monitoring of blood pressure and reduction of medication as required.
  • Diuretics are usually stopped, based on physician's assessment, for the VLCD phase (unless there is heart failure).
  • For patients using warfarin, monitor INR.
  • Lithium, antiepileptics: monitor levels.

Lifestyle guidance in practice

  • Lifestyle guidance (lifestyle counselling) can be given on individual visits or in groups.
  • To save costs, digital tools available can be used for counselling for example in cases where there are no other forms of treatment available at the unit.

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