Discuss the risks of supplements. Patients are bombarded by advertisements for dietary supplements. You can help by initiating a discussion of the lack of evidence of the efficacy and/or safety of most such products.
The most widely used herbal supplement, ephedrine, was taken off the market in 2006 for safety reasons. The US Food and Drug Administration recommends avoiding many over-the-counter dietary products because a significant number of them have been found to contain undeclared active prescription ingredients.39
In general, published trials of dietary supplements are of suboptimal quality. There is limited evidence that caffeine may have a positive effect on thermogenesis and fat oxidation.4 A review of 1 promising dietary supplement, chitosan, found that the effect was minimal and unlikely to be of clinical significance.40 The evidence is weak for meaningful changes in weight or body composition for green tea catechins, conjugated linoleic acid, and chromium picolinate. Dietary calcium appears to aid in weight management, but the magnitude is controversial.41 Preliminary data about amino acids and neurotransmitter modulation are promising, but too little is currently known about these approaches.42 Fiber supplements, unlike most dietary supplements, are recommended, as dietary fiber decreases food intake and hunger.
Pharmacotherapy may boost weight loss. Two types of weight loss drugs—a lipase inhibitor (orlistat [Xenical]) and an appetite suppressant (sibutramine [Meridia])—are on the market. Research shows that pharmacotherapy, when combined with diet or physical activity, may enhance weight loss (usually <11 lb/year) in some adults, although the optimal duration of drug use has not been determined.16,17,43,44 The choice of medication should be based on the expected response to the medication. There is no evidence that either medication promotes more sustained weight loss than the other. In clinical trials, however, sibutramine produced a weight loss of 4.9 lb more than orlistat.44
While patients with hypertension have been found to achieve modest weight loss using either agent, orlistat reduced both diastolic and systolic pressure, while diastolic blood pressure increased with sibutramine.45 Metformin may help prevent excess weight gain associated with short-term use of atypical antipsychotics, although its use for this purpose is off-label.46
When to consider bariatric surgery
Bariatric surgery continues to provide greater sustained weight loss and metabolic improvements than other conventional treatments.47 Identify patients who have failed at comprehensive weight loss programs and who are at high risk for obesity-associated morbidity and mortality (TABLE 1), and discuss the benefits (eg, reduction in comorbidities and at least a short-term improvement in health-related quality of life) and risks (eg, pulmonary embolism, anastomosis leakage, procedure-specific problems such as band slippage and erosion [after gastric banding], and possibly even death) of bariatric surgery. Refer potential candidates to an appropriate surgeon and facility.
Be aware, however, that the field of bariatric surgery is rapidly changing in terms of types of procedures, standards for perioperative care, patient selection, and reimbursement policies,48,49 and patients need to check with their insurance company before making any treatment decisions.
Common bariatric procedures include Roux-en Y gastric bypass (the gold standard); adjustable gastric banding; biliopancreatic diversion; and sleeve gastrectomy. Most are done laparoscopically. The sleeve gastrectomy, in which a vertical sleeve is created while much of the stomach is removed, may be useful for patients who are high-volume eaters, or to prepare extremely obese patients for gastric bypass. Patient selection is important, and multidisciplinary care is generally considered essential. After the surgery, the FP will play a key role, monitoring the patient’s medications, nutrition, physical activity, chronic conditions, and overall quality of life.
Adopt a team approach
Encourage your office staff to review the Surgeon General’s Vision for a Healthy and Fit Nation 2010 (www.surgeongeneral.gov/library/obesityvision/obesityvision2010.pdf), which focuses on promoting, modeling, and working with patients to achieve a healthy lifestyle. The Surgeon General advocates a team approach to weight management, and recommends that patients have referrals to dietitians, psychologists, and community services.17,50
Interventions that include not only lifestyle modifications, but also behavioral modifications, such as hypnosis, can also be helpful. Computer-based strategies, such as Internet-based weight management programs and automated messaging, may be useful, as well, to break down barriers resulting from factors such as cost, time constraints, and lack of transportation or child care.51 Even when such programs are in use, however, it is important to remember that patients value—and benefit from—the support of their primary care physician.
Acknowledgement
This work has been presented in various Continuing Medical Education programs to audiences in North Carolina.