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Although advice on lifestyle and behavioral change should always come first when treating obesity, new practice guidelines issued by the American College of Physicians (ACP) describe how to decide when drugs or bariatric surgery may be appropriate.1
The ACP guidelines, published in April in the Annals of Internal Medicine, are based on papers examining pharmacologic and surgical treatments for obesity by the Southern California-RAND Evidence-Based Practice Center (EPC). The ACP has recommended that these drug and surgery guidelines be added to those of the U.S. Preventive Services Task Force, an effort of the Agency for Healthcare Research and Quality (AHRQ) "as part of an overall strategy for managing overweight and obesity."
"We wanted to provide our members with the best evidence-based guidance for treating their patients with obesity," says lead author Vincenza Snow, MD, director of clinical programs at the ACP.
DIET AND EXERCISE
The ACP advises all physicians to engage in a long-term commitment to their obese patients, and it encourages doctors to determine each patient's individual weight-loss goals and expectations before treatment even begins. The guidelines recommend that other health-related goals, such as decreasing blood pressure or fasting blood glucose levels, also be incorporated in the treatment plan.
Counseling on nutrition and physical activity should be the first step in
treating patients who have a body mass index (BMI) 
30, the ACP paper
concludes.
"Diet, exercise, and behavior modification should be the cornerstone to any other treatment," agrees Christopher Still, DO, director of the High Risk Obesity Clinics at Geisinger Health Care System in Danville, Pa.
Acknowledging that there is no evidence that behavior change alone reduces rates of obesity-linked death or illness, the ACP nonetheless notes that modest weight loss (5–10%) can produce positive outcomes such as improved glucose metabolism, lipid levels, and blood pressure.
Similarly, the American Diabetes Association (ADA), North American Association for the Study of Obesity (NAASO), and American Society for Clinical Nutrition (ASCN) statement on the treatment of overweight and obesity says "moderate weight loss improves glycemic control, reduces cardiovascular disease (CVD) risk, and can prevent the development of type 2 diabetes."2
According to the statement, the primary approach for achieving weight loss in "the vast majority of cases" is lifestyle change that focuses on reducing energy intake and increasing physical activity. The joint ADA, NAASO, ASCN statement provides more specific diet, nutrition, and exercise recommendations, in terms of goals for calorie intake and frequency and duration of activity, than the ACP guidelines, and the statement makes little reference to use of drug or surgical therapy.
Meanwhile, the ACP statement is intended to complement the obesity guidelines on lifestyle-change interventions supported by AHRQ's task force by providing specific recommendations for use of weight-loss medication and surgery.
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DRUG THERAPY
If an obese patient does not respond to the combination of diet and exercise, the ACP suggests clinicians may offer drug therapy as an adjunct. The guidelines list six pharmacologic options that are either appetite suppressants or lipase inhibitors, also known as fat-blocking medications:
"For some people with BMIs >30, the drugs in conjunction with diet and exercise are effective, but only for producing moderate amounts of weight loss," Snow says.
While medical weight loss is a popular choice for obesity treatment, some drugs' side effects can be serious. Patients reportedly have experienced an increase in heart rate and blood pressure, gastrointestinal side effects, nausea, and tremors. Five drugs have been removed from U.S. and international markets because they were no longer considered safe and effective.
The ACP guidelines recommend that, before prescribing any drug, the doctor have a discussion with the patient about side effects and the realistic sustainability of the weight loss.
The authors are candid about the limitations of the evidence for drug therapy. "There are no data to determine whether one drug is more efficacious than another, and there is no evidence for increased weight loss with combination therapy," they write. "There are no data about weight regain after medications are withdrawn, underscoring the need for sustained lifestyle and behavior modifications."
Daniel H. Bessesen, MD, chief of endocrinology at the Denver Health Medical Center, says many physicians think drugs don't work, have too many side effects, and are expensive. Some may even think prescribing weight-loss medications is unethical, he adds.
But Bessesen says he is comfortable prescribing drugs in certain situations because the physician has the opportunity to understand the patient's medical history, as well as his or her attitudes and experiences with drugs and other weight-loss therapies.
"Our job is not to make the decision whether side effects are intolerable, but to explain what the side effects are and to help the patient make a reasonable decision," Bessesen says.
BARIATRIC SURGERY
An increasingly popular option is weight-loss surgery. In people who are
morbidly obese (BMI 40), drug therapy may not always be effective, says
Henry Buchwald, MD, PhD, director of the Fairview University Obesity Surgery
Center at University of Minnesota and chair of a consensus panel that has
released a new statement on the effectiveness of bariatric surgery (see
sidebar on page 7).
"If you have a patient who is morbidly obese and has hypertension and you treat them with a nonoperative drug, you can keep the condition in check," Buchwald says. "But you don't fix it."
Bariatric surgery should only be considered if the patient has a BMI 40
and has attempted but failed a diet and exercise regimen, the ACP guidelines
suggest. These patients also should present with an obesity-related comorbid
condition, the authors continue, such as hypertension, impaired glucose
tolerance, type 2 diabetes, hyperlipidemia, or obstructive sleep apnea. The
National Institutes of Health 1991 guideline concludes surgery may be
appropriate for those with a BMI 35 and a comorbid condition.
ACP identified four commonly performed surgical options: Roux-en-Y gastric bypass (RYGB), adjustable gastric banding, biliopancreatic diversion with duodenal switch, and vertical banded gastroplasty. The authors write that they found no current randomized, controlled trials comparing patients treated with today's bariatric surgical procedures with a control group not treated with surgery.
Surgery can have "high postoperative complication rates," the ACP authors note. Patients could experience surgical complications, gall bladder disease, and poor digestion. The reported mortality rate ranges from 0.3% to 1.9% per 100 surgeries.
"There are differences among the surgeries, so patients need to understand the risks of complications from surgery as well as complications farther down the road, such as gall bladder disease and sometimes reoperations, not to mention the need to sustain lifestyle changes," Snow says.
The surgeon's experience is an important consideration, according to the guidelines. The ACP recommends that clinicians refer surgical candidates to high-volume centers. The ACP cites one study that showed patients of surgeons who performed fewer than 20 surgeries had a 5% mortality rate, compared with almost 0% mortality in patients of surgeons who had performed more than 250 procedures.
As the number of bariatric surgeries increases, primary care providers will play a larger role in the management of pre- and postoperative care. In most cases, this means continuing to beat the drum urging patients to attempt to shed at least some weight with lifestyle change.
Diet, exercise, and behavior modification, combined with bariatric surgery, may be the best treatment approach, Still says. He notes that patients in his clinic must approach a 10% weight-loss goal before surgery is considered.
"The patient will not get as good an outcome if diet and exercise aren't used before surgery," Still contends. "Surgery should not be the first step, but it should be a viable tool."
And although some say evidence that preoperative exercise benefits surgical
outcomes is limited, and note that very obese people may have difficulty even
walking prior to surgical weight loss, Elliot Goodman, MD, a bariatric surgeon
at Beth Israel Medical Center in New York City, also stresses lifestyle
change. "If they haven't tried it, I'm not going to operate," he
says. 
ASBS PANEL: SURGERY MOST EFFECTIVE FOR TREATING MORBID OBESITY
A panel of 12 multidisciplinary medical experts has concluded that weight-loss surgery is the most effective approach for managing morbid obesity.
In a consensus statement published in April, the group says bariatric surgery safety has improved significantly and its risk profile is comparable to other surgical procedures. The statement is a result of a 2004 conference of the American Society for Bariatric Surgery (ASBS) and the ASBS Foundation.1
It is the first consensus statement on the subject of bariatric surgery since the National Institutes of Health (NIH) published "Gastrointestinal Surgery for Severe Obesity" in 1991. The new statement says bariatric surgery can improve life expectancy and eliminate or resolve some comorbid conditions of morbid obesity, including type 2 diabetes and heart disease.
"[Bariatric surgery] results in 50% loss of excess body weight—sometimes even 70%," says Henry Buchwald, MD, PhD, chair of the consensus panel and director of the Fairview University Obesity Surgery Center at University of Minnesota. "It's common sense that the treatment of choice for morbidly obese patients with diabetes is bariatric surgery."
According to the panel, which included clinicians and researchers in epidemiology, pediatrics, endocrinology, nutrition, internal medicine, psychology, and surgery, the standard of care for bariatric surgery includes both laparoscopic and open techniques. Buchwald says he hopes the consensus statement "will help millions of people in this country who are morbidly obese and have run out of options."
References
2. American Diabetes Association: Standards of medical care in
diabetes (Position Statement). Diabetes Care 28: S4–S36, 2005.
1. Buchward H, for the Consensus Conference panel: Bariatric surgery for morbid obesity: Health implications for patients, health professionals, and third-party payers. J Am Coll Surg 200: 593–604, 2005.[Medline]
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