Obesity imposes a substantial health burden and has increased in prevalence in recent years. Despite its health impacts, obesity remains undertreated in primary care settings because of a variety of barriers. Recommended approaches to the clinical management of obesity require an understanding of the physiology of the condition, as well as patients’ perspectives and effective nonpharmacologic and pharmacologic treatment options. Notably, recent approvals of new pharmacologic agents for weight management offer clinicians additional options to implement as part of an individualized weight management strategy for patients.
In a series of short videos now available on the Clinical Diabetes website, the authors discuss the burden and impact of obesity as a disease, approaches to communication and patient motivation for obesity management, and available evidence-based treatments. They also discuss practical considerations for implementing these interventions in the primary care setting.
This article is intended to serve as an executive summary of this video series. The video series described below is available in its entirety at https://diabetesjournals.org/clinical/pages/overweight_and_obesity_management. Short biographies of the authors and links to generate continuing education credits for viewing the series are also available at this website.
Obesity as a Disease (Video 1)
Obesity is a significant public health burden globally and in the United States. Since 1975, the prevalence of obesity worldwide has tripled (1). In the United States, average BMI rose from 24.9 kg/m2 in 1975 to 28.9 kg/m2 in 2016. The obesity rate increased from 30.5% in 1999–2000 to 41.9% by March 2020, and the rate of severe obesity increased from 4.7 to 9.2% over that same interval (2,3).
Although historically underrecognized and undertreated, obesity has been designated a disease by professional organizations and government agencies (4,5). In the first video of this series, the authors review the burden and pathophysiology of obesity, including hormonal adaptations and lifestyle behaviors.
Obesity as a chronic disease is characterized by the presence of increased adipose tissue that harms health (6). Obesity has a significant negative impact on quality of life and is associated with substantial health care expenditures. In the United States, the percentage of national medical expenses for treating obesity-related illness increased from 6.1% in 2001 to 7.9% in 2013 (7). Additionally, annual medical costs of obesity in the United States are estimated to be $173 billion in 2019 dollars (2). Despite the impact of obesity, it is frequently undertreated (4).
Primary care practitioners often address obesity-related comorbidities such as type 2 diabetes, hypertension, cardiovascular disease, and nonalcoholic steatohepatitis. However, obesity itself is not often directly addressed (4). According to data from the National Health and Nutrition Examination Survey 2011–2018, only 40% of adults with obesity or overweight were counseled to lose weight (8). Additionally, in the U.S. national ACTION (Awareness, Care, and Treatment in Obesity Management) study (9), only 55% of adults with obesity reported received a diagnosis of obesity, and 24% reported follow-up contact with a clinician after the initial weight-related discussion.
The development of obesity is a multifactorial, complex process that involves physiologic mechanisms as well as lifestyle behaviors (10). The authors discuss the relationship between food intake, metabolism and energy expenditure, and physical activity as it relates to obesity. They also discuss lifestyle behaviors such as low fruit and vegetable consumption, low levels of physical activity, tobacco use, and alcohol use that contribute to obesity.
Communication and Nonpharmacologic Treatment (Video 2)
Communicating clearly with patients about obesity is an essential part of providing obesity care, but doing so is not always easy. However, just opening a discussion about weight can lead to weight loss in patients with varying degrees of overweight or obesity (11). Additionally, some communication methods such as the “5 As” approach have demonstrated benefits in patients with obesity (Figure 1). Using the 5 As approach while talking to patients may increase the likelihood of initiating obesity treatment and better motivate patients to lose weight (12,13).
Whether intentionally or unintentionally, weight bias can be introduced into clinicians’ interactions with patients. Weight bias involves predetermined notions regarding patients’ character based on their weight status; many clinicians even report having adverse views of patients with obesity (14). Weight bias can have a significant impact on patients. Patients can acquire maladaptive eating patterns such as coping with stigma by eating more food (15). Additionally, weight bias tends to impair weight loss and can result in other social and economic problems (16).
When initiating discussions about weight loss, clinicians should consider documenting and discussing patients’ baseline BMI and setting realistic expectations for weight loss goals. Education regarding the risk associated with various levels of BMI, including both overweight and obesity, can be an effective intervention (17). Clinicians should also enhance processes for accurately diagnosing, documenting, and coding obesity based on BMI in the electronic medical record system. This practice is beneficial for the accuracy of patients’ medical records for ongoing care, as well as for population health purposes (18).
The authors then discuss nonpharmacologic approaches to treating obesity, starting with dietary interventions. Despite the vast array of dieting advice and public interest in various diets, the simple truth is that a negative energy balance is needed for weight loss, regardless of the specific macronutrient content in the meal plan (19). However, patients can be guided in the selection of an appropriate diet, and the best diet intervention is the one to which the patient can adhere (20).
Video 2 ends with a review of the benefits of exercise—specifically aerobic exercise—in weight loss (21). Several studies have demonstrated health benefits from ≥150 minutes per week of moderate-intensity aerobic exercise, including reduction in cardiovascular disease and cancer risk, and this can be accomplished simply by increasing the number of steps taken in a day (22).
With the exception of surgical procedures, the most effective weight loss strategy is to combine nonpharmacologic interventions with pharmacologic therapy (4). Nonpharmacologic therapy forms the foundation for successful obesity treatment, in which the degree of weight loss is associated with a corresponding reduction in health risks.
Pharmacologic Treatment (Video 3)
Several pharmacologic agents are approved by the U.S. Food and Drug Administration for weight management and are often characterized as “short-term” or “long-term” treatments. The purpose of pharmacologic therapy is to help patients with obesity continue lifestyle interventions and achieve successful weight loss by targeting the body’s adaptation mechanisms that resist weight loss (4). In video 3, the authors discuss pharmacologic treatment options for obesity management, reviewing guideline recommendations and offering practical advice for individualizing therapy.
Pharmacologic therapy is indicated for people with obesity if their BMI is ≥30 kg/m2 or if their BMI is ≥27 kg/m2 and they have an obesity-related comorbidity such as type 2 diabetes, hypertension, obstructive sleep apnea, or dyslipidemia (23). Pharmacologic therapy can help these individuals experience greater weight loss, decreased waist circumference, and improved weight loss maintenance (24). Notably, if a patient has not experienced a significant reduction in body weight after taking a weight loss medication for 3 months, the medication should be stopped, and treatment options should be reassessed (23).
Three clinical guidelines inform obesity management in the United States: a 2013 guideline from the American Heart Association, the American College of Cardiology, and the Obesity Society; a 2015 guideline from the Endocrine Society; and a 2016 guideline from the American Association of Clinical Endocrinology/American College of Endocrinology (19,23,25). The authors review key recommendations from these guidelines and discuss their applicability to obesity management in primary care settings.
The authors also discuss obesity medications for both short-term and long-term use, their mechanisms of action, and dosing and clinical considerations for each. More data are available for long-term medications, many of which are prescription medications such as liraglutide, naltrexone/bupropion extended release, orlistat, phentermine/topiramate extended release, and semaglutide (4). Considerations for individualizing therapy based on risk factors and comorbidities are also addressed.
Other Treatment Options and Key Takeaways (Video 4)
Aside from lifestyle intervention and pharmacologic therapies for treating obesity, bariatric surgery and various medical devices are also available (19). Although bariatric surgery generally requires referral to a specialist, primary care clinicians can assist with patients’ preparation for and follow-up care after such procedures (26). In the final video of this series, the authors describe surgical procedures and medical devices that can assist with weight loss.
Common bariatric surgical procedures include the Roux-en-Y gastric bypass, laparoscopic adjustable band, laparoscopic gastric sleeve, and biliopancreatic diversion with duodenal switch (27). In a Swedish outcomes study, gastric bypass or banding resulted in a 29% reduction in all-cause death and an average of 66% fewer strokes (28,29). Longstanding general consensus holds that bariatric surgery should be considered a treatment option for obesity in patients with a BMI ≥40 kg/m2 or a BMI ≥35 kg/m2 in those with at least one obesity- related comorbidity (e.g., type 2 diabetes, sleep apnea, or fatty liver disease) (26).
Medical devices that can assist with weight loss include stomach space–occupying devices and an oral palatal space–occupying device. One type of stomach space– occupying device, the intragastric balloon, is delivered to the stomach either endoscopically or by swallowing (30). It is then filled with air or fluid to reduce the available space for food or liquids in the stomach, encouraging reduced caloric intake. Another stomach space–occupying device is ingested capsules that absorb large amounts of water. These capsules mix with food and increase its volume, promoting satiety (31). The intragastric balloon tends to result in more weight loss (target 10–12% versus 6% with the capsules), but it is associated with more pain than the ingested capsules, especially when removed (26,32).
The oral palatal space–occupying medical device is worn over the palate of the mouth and results in weight loss of ∼2% over 16 weeks. However, this device is only indicated for patients with a BMI of 27–35 kg/m2 (30). The authors conclude this final video with a discussion of their experience with bariatric surgery and medical devices in practice and briefly summarize key points of the video series.
The production of this video series and associated materials was funded by an educational grant from Novo Nordisk. Writing and editorial support for the preparation of the series and its executive summary were provided by Austin Ulrich, PharmD, on behalf of the Illinois Academy of Family Physicians, the Primary Care Metabolic Group, and the Primary Care Education Consortium. The content for this article and the associated video series was produced according to the policies of the Accreditation Council for Continuing Medical Education. Novo Nordisk had no input into the topic, forum discussion, or any content for this article or its accompanying videos.
Duality of Interest
J.A. serves as a consultant or on a speakers bureau for Abbott Diabetes Care, Alfa Sigma, AstraZeneca, Bayer, Eli Lilly, Gelesis, Insulet, Novartis, Novo Nordisk, and Sanofi. R.K. serves on advisory boards or as a consultant for Altimmune, Lilly, Novo Nordisk, Pfizer, and WW. E.M. serves on advisory boards and/or speakers bureaus for or is a consultant to Abbott Diabetes Care, AstraZeneca, Boehringer-Ingelheim, Eli Lilly, Merck, and Novo Nordisk and has received research support from Abbott Diabetes Care and Pendulum. C.S. has contracted research for and served as a consultant to or on a speakers bureau for Ethicon Endosurgery and Novo Nordisk. No other potential conflicts of interest relevant to this article were reported.
J.A. organized and structured data presentation for this manuscript. R.K., E.M., J.N., and C.S. provided data or materials and overall review for this manuscript. J.A. is the guarantor of this work, and, as such, had full access to all the data included and takes responsibility for the integrity of the data and the accuracy of the data analysis.