Conservative (non-surgical) treatment of obesity

EBM Guidelines
15.8.2019

Essentials

  • Effective methods are available for the treatment of obesity.
  • Realistic target weights should be set, i.e. about a 5–10% reduction in weight.
  • The methods of motivational interviewing promote the realization of changes.
  • Patients must want to make the necessary changes to their dietary and exercise habits.
  • Some patients succeed in reducing weight on their own after they have received an initial assessment of the situation, necessary information and positive encouragement in the health care services.
  • Many patients require professional long-term guidance and support.

Treatment approaches evd

  1. Mini-intervention. The weight problem is discussed briefly, and the patient is given relevant advice after which he/she will carry out weight reduction unaided.
  2. Gradual and permanent modification of lifestyle through counselling and guidance
    • This is the "basic" obesity treatment suitable for everybody.
    • Usually carried out in a group that meets 6–15 times. Indicated in mild to moderate obesity, and in the majority of cases of severe obesity; should be included in all forms of medical treatment regardless of the ailment being treated.
    • May be carried out digitally in patients suitable and motivated for this mode of treatment. Find out about services available locally.
  3. An introduction of a very low calorie diet (VLCD) together with guidance
    • Indicated mainly in severe (BMI > 35) to morbid (BMI > 40) obesity.
    • May also be used in moderate obesity (BMI > 30) if mere guidance has been unsuccessful and there is a strong indication for weight reduction (obesity-related diseases).
    • The VLCD phase lasts usually 8–12 weeks. It requires a long follow-up and a systematic treatment plan to prevent weight gain after the VLCD phase.
  4. Drug therapy (orlistat, naltrexone/bupropion or liraglutide)
    • May be considered as an alternative when other treatment approaches have failed.
    • Drug therapy must always be accompanied by lifestyle counselling.
    • May also be combined with the weight management phase after the VLCD (first VLCD, after which drug therapy).
  5. Surgery «Bariatric surgery (obesity surgery)»1
    • Considered for selected patients with severe to morbid obesity (see criteria below).
    • Assessment of suitability for surgical treatment is done within specialized health care.

Mini-intervention evd

  • A patient’s excess weight should be discussed during an appointment whenever it appears appropriate.
  • Obesity and its treatment are discussed with the patient in a positive manner, utilizing a patient-centred working method. This entails that the background and life situation of each patient is taken into account and provision of top-to-bottom type of advice is avoided.
  • A good policy is to frequently weigh patients which makes discussion about their weight easier.
  • A suitably neutral question to open the discussion is: ”How do you feel about your weight?” or “How has your weight development been?”
  • The discussion is then continued with a couple of open questions, like ”What do you think about your eating habits?”, “It would be interesting to hear what kind of things you find to easily increase your weight?” or “What would be the easiest lifestyle change that would help you in weight management?”
  • The impact of obesity on the patient's well-being is discussed by asking the patient first how he/she thinks the obesity affects him/her. Placing the discussion in context with regard to the patient's own health history, issues talked about may also include the increased risk of developing disease and the benefits of weight loss in promotion of health.
  • The principles of weight reduction are discussed. The topics may include e.g. that losing only a few kilos will reduce the risk of many diseases, increasing the amount of fruit and vegetables in the diet is beneficial, it is worthwhile to reduce sitting and to find a form of exercise that it suitable for oneself.
  • The patient is informed about various methods of weight management and weight reduction, as well as their practical implementation. Treatment methods of obesity include basic treatment (promotion of healthy living habits), very low energy diet (VLCD), pharmacotherapies and surgery.
  • The patient is encouraged to monitor his/her weight regularly (at least once a week) and to ensure that the weight does at least not increase (usually an overweight individual gradually gains weight over the years). Weighing oneself is not necessarily suitable for all patients, particularly if there are underlying eating disorders.
  • An agreement can be made on some small concrete change that would help in weight management. The agreement is entered in the patient records so that it is available for the next visit.
  • The patient may be given printed information about weight reduction or told where to find such information.
  • The patient should be asked about the progress of weight reduction during future appointments.

Basic obesity treatment evd

Organisation

  • Group treatment is less costly and as effective as individualised treatment.
    • 6–15 meetings, first at about one-week intervals, then less frequently.
    • The length of the group treatment should be at least 6–months, preferably 12 months. Many long group treatments contain e.g. 15 meetings.
    • The group size should be 10–15 persons.
    • The group leader should be a nurse or a dietitian with special training in the treatment of obesity. It is recommended to also have a physiotherapist or an exercise trainer and, depending on resources, a psychologist involved. A physician can visit the groups and organize e.g. a physician’s question hour.
    • The group meetings should preferably be active (include physical activity), not mere sitting.
  • The primary health care unit that arranges the group sessions should draw up instructions on the management of the basic treatment (principles of recruiting patients in the groups, possible follow-up etc.).
  • Experience has shown that weight-reduction groups do not function well if the care unit does not dedicate a physician to take overall responsibility of the management of obesity. This gives the group leaders the opportunity to discuss problematic patients and other questions that may arise.
  • Instead of group treatment, also individual treatment may be provided, if resources for that are available.
  • Individual treatment may be provided digitally, e.g. when no other treatment mode is available within the health care unit.

Patient selection

  • Only a small proportion of overweight patients can be offered basic obesity treatment, and therefore patients who are likely to benefit most should be chosen.
  • Basic obesity treatment should be offered to all obese patients with newly diagnosed type 2 diabetes.
  • Other indications for basic obesity treatment include the presence of metabolic syndrome, sleep apnoea and other obesity-related diseases.
  • The younger the patient the more important it is that basic obesity treatment is offered.
  • The importance of maintaining exercise and preserving muscle mass is emphasized by age, particularly after retirement.
  • Intense weight reduction should be avoided in patients above the age of 65–70.

Measurable goals

  • An acceptable rate of weight reduction is approximately 0.5 kg/week. A less rapid rate of weight loss is also possible.
  • The goal should be a permanent weight reduction of 5–10%, which is enough to significantly benefit the treatment of obesity-related diseases.
  • The goal should always be to maintain as permanent a result as possible, which means long-term planning and permanent lifestyle modifications.

Counselling and its aims evd

  • The principles of motivational interviewing «The role of motivational interviewing in changing lifestyles and in treatment»2 should be followed: the patient him-/herself evaluates his/her dietary and exercise habits and, based on the knowledge provided by the instructor, decides about the changes to be made.
  • A coaching approach is used instead of top-down instructions and guidance. Encouraging the patient in a positive tone is essential.
  • It is often useful to identify connections between feelings and eating.
  • The most important goal should be to change habits, not to ”obsess over the scales”. The goal is to find new, flexible living habits. Too tight limitations are rarely permanent.
  • Human energy needs decrease when the body weight reduces. In order to maintain the weight loss, all lifestyle changes must be permanent.
  • Changes can be carried out gradually: one can start with 1–2 changes and try more later on.
  • Principal means to reduce calorie intake are listed below.
    • Regular rhythm of meals is central in the regulation of appetite (breakfast, lunch, dinner and snacks according to need).
    • The main emphasis is put on reducing the energy density of the diet by decreasing the intake of fatty foods and by increasing the intake of vegetables (e.g. applying different "healthy plate" models).
    • Liquid milk products should be fat-free, other drinks mainly calorie-free (water, sugar-free soft drinks).
    • Reduction of excessive alcohol consumption
    • Large portions of food should be avoided.
    • Intake of protein should be sufficient (80–120 g/day)
    • Small daily changes are effective in the long run.
  • Changes in physical exercise
    • Physical inactivity in the everyday life should be recognized, and the amount of sedentary time should be decreased.
    • Exercise during daily activities should be encouraged (increased muscular exertion by climbing up stairs, walking or cycling to work etc.)
    • Target: at least half an hour daily most days of the week such exercise that the patient is able and willing to perform.
    • If a pedometer is used, the target should be at least 10 000 steps per day.
  • Other means
    • The motivator for eating should be identified. Pleasure or hunger?
    • Towards the end of a meal the patient should evaluate when he/she is suitably full and stop eating right then.
    • Food shopping should be done strictly in accordance with a shopping list.
    • The number of temptations must be reduced (no energy-rich food in sight).
    • The individual must not engage in other activities when eating (no TV, no reading).

Very low calorie diet (VLCD)

  • The VLCD product should contain
    • energy usually 1 700–2 100 kJ (400–500 kcal), up to the maximum of 3 300 kJ (800 kcal), per day
    • protein at least 50 g daily; this is too little for most; it is recommended to ensure sufficient protein intake by eating besides the dietary product also about 100 g of low-fat meat or fish daily, which gives an additional 20 g of protein.
    • daily requirements of essential fatty acids, trace elements and vitamins.
  • Schedule
    • The diet consists of commercial formulas that fulfil the VLCD criteria.
    • The diet should be used according to its instructions. The products may include e.g. 5 (women) or 6 (men) sachets for one day. Every day additionally the following (unless for some reason contraindicated): 500 g of low-carbohydrate vegetables and 100 g of protein-containing food substance (of which 20 g protein) with no carbohydrates.
    • The food replacement diet should be consumed for 8–12 consecutive weeks. It is important to provide advice on the long transition phase back to normal diet and to monitor the patient in order to avoid the regaining of weight; see below.
    • During the diet the patient is monitored at about 2-week intervals and in the weight management phase at 2–4 week intervals. The frequency is adjusted on the individual basis and, if resources allow, the monitoring may take place even more frequently.
    • The diet may be discontinued earlier if a body mass index (BMI) of 25 kg/m2 is reached or if the diet causes adverse effects.
    • VLCD is well suited, for example, for patients with type 2 diabetes or hypertension. See article Oral antidiabetic drugs and GLP-1 analogues «Oral antidiabetic drugs and GLP-1 analogues»3 for more information on drugs.
      • In patients with type 2 diabetes, mealtime insulin is stopped completely, basal insulin is at least halved, and the insulin dose is thereafter adjusted according to blood glucose measurements.
      • Sulphonylurea and glinide (prandial glucose regulator) medications are stopped before starting VLCD.
      • SGLT2 inhibitors are stopped before starting VLCD (risk of dehydration and ketoacidosis).
      • GLP-1 analogues are 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 topical as the weight is reducing. It is possible that medications have to be started again after VLCD (based on blood glucose measuring).
      • Antihypertensive drugs are 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 coronary insufficiency)
    • The rate of weight reduction is about 1.5–2 kg/week, and the immediate weight reduction is 2–2.5 times greater than that attained with basic obesity treatment. Randomized trials have, however, not shown any significant difference in long-term results as compared to basic treatment carried out without VLCD.
    • Due to the tendency of rebound weight gain, a gradual withdrawal from the diet can be used, with a speed of one pack/week. 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 and 3 packs/day and so on. In this manner the gradual discontinuation of VLCD takes about 5–6 weeks.
    • After this, the program should include planned weight management phase (preferably > 6 months), during which the patient remains within health care services for monitoring. When planning permanent lifestyle changes, take into account the 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 situation one may e.g. start using again more VLCD sachets 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 is offered a possibility to contact 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.

Drug treatment evd

  • Medication can be tried to support lifestyle changes, if the basic treatment 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.
  • An anti-obesity drug should only be considered for those with BMI over 30 (or over 27 in the presence of diabetes or other disease that warrants weight loss).
  • The patient should be informed that drug treatment may last for several years. On stopping medication, a gradual reversal of weight loss is usually seen. At the time of stopping the medication, special attention should be paid on following up the weight and on application of lifestyle changes that are aimed at prevention of weight regain.
  • Drug treatment should be discontinued if the individual has not lost a sufficient amount of weight within 3 months (at least 5% of the baseline weight).
  • Drugs indicated for the treatment of obesity include orlistat, naltrexone/bupropion and liraglutide 3.0 mg.

Orlistat evd

  • 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 reduce more than it would with weight reduction alone.
  • Orlistat is used in association with main meals, three times daily.
  • Policies concerning the sales of orlistat may vary from country to country; in Finland, orlistat 120 mg is a prescription drug, whereas orlistat 60 mg is 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 a consumption of fatty foods.
  • Orlistat may reduce the absorption 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 rather in the evening before going to bed).
  • In two-year follow-up a dose of 60 mg thrice daily (weight loss 7% of initial weight) and 120 mg thrice daily (weight loss 8%) reduced weight significantly more than lifestyle treatment alone (placebo group [4.5%]).
  • Differences in health insurance coverage may exist in different countries.

Naltrexone/bupropion

  • The effect of a combination product of naltrexone (8 mg) and bupropion (90 mg) comes about primarily through reduction of appetite. This effect is utilized by combining the drug therapy with comprehensive lifestyle counselling.
  • The most common adverse effects include nausea, vomiting, constipation, dry mouth, sleeping problems, dizziness and tremor. Blood pressure and heart rate may increase. A separate checklist for indications may be available by local pharmaceutical authorities.
  • Not to be used by patients with hepatic or renal insufficiency, with uncontrolled hypertension or with a history of seizures.
  • In one-year follow-up the weight loss was 6.1%, significantly higher than by lifestyle treatment alone (placebo group [1.3%]). In a treatment mode utilizing behaviour therapy, in one-year follow-up the weight loss was 9.3% in the drug group and 5.1% in the placebo group.

Liraglutide

  • Liraglutide is a GLP1 (glucagon-like peptide 1) analogue. GLP1 is secreted by the L cells in the bowel and it has several target organs. 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 used for type 2 diabetes at doses of 1.2–1.8 mg once daily.
  • Due to liraglutide's mechanism of action, blood glucose concentration reduces more than caused by weight loss alone.
  • Administration is by a subcutaneous injection (in the morning).
  • Liraglutide reduces appetite particularly in large doses. This appetite-reducing property is utilized by combining the drug therapy with good lifestyle counselling.
  • The dose in the treatment of obesity is 3 mg once daily. The initial dose of 0.6 mg once daily is increased by steps of 0.6 mg at e.g. 2-week intervals.
    • The appetite-reducing pharmacological feature is best utilized in the treatment of obesity by associating the drug treatment with comprehensive lifestyle counselling.
  • The most common adverse effects include nausea, diarrhoea, abdominal pain and digestive disturbances. Hypoglycaemia is possible, particularly in combination with other hypoglycaemia-inducing drugs.
    • Nausea usually subsides within a month. It can be reduced by increasing the drug dosage more slowly.
  • In one-year follow-up the weight loss was 8.0%, significantly more than using lifestyle treatment only (placebo group [2.6%]); similar results were acquired in 3-year follow-up (weight reduction 6.1% in drug group and 1.9% in placebo group).
  • Differences in health insurance coverage may exist in different countries.

References

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  2. Greenway FL, Fujioka K, Plodkowski RA ym. Effect of naltrexone plus bupropion on weight loss in overweight and obese adults (COR-I): a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2010;376(9741):595-605. «PMID: 20673995»PubMed
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