New guidelines give the skinny on obesity management

The American College of Physicians (ACP) recently issued guidelines for the management of obesity. Prepared by ACP's clinical efficacy assessment subcommittee, the paper was published in the April 5 issue of Annals of Internal Medicine.

"Our guidelines committee made a policy decision that it would try to develop guidelines that complement those of the U.S. Preventive Services Task Force (USPSTF)," said Vincenza Snow, M.D., the lead author of the guidelines and the director of clinical programs at the ACP. "The task force recently issued guidelines on screening for obesity. The committee also saw a need for evidence-based guidelines to help primary care physicians assist their patients in choosing the appropriate treatment.

"Members of the committee saw an epidemic of obesity in their own practices," Snow continued. "So between the recent USPSTF guidelines and that increased incidence, the committee felt it had to do this."

Body Mass Index (BMI) should be determined for every patient as if it were a vital sign, said Snow. She mentioned that the guidelines stress the importance of using BMI to choose a therapy. The authors of the guidelines recommend that clinicians counsel all patients with a BMI of 30 kg/m² or greater about lifestyle and behavioral modifications, such as diet and exercise. They also recommend that bariatric surgery be considered for those with a BMI of 40 kg/m² or greater.

Snow went on to say that no matter what treatment is deemed appropriate, if a diet and exercise program is not in place, the therapy will not work. A diet and exercise program should be recommended for all obese patients, and patients should be continuously educated regarding the importance of diet and exercise, said the authors.

As for medications to treat obesity, "we wanted our members to know that although several moderately efficacious drugs for obesity have been approved, no long-term studies of their safety and efficacy have been done," Snow said. "Unfortunately, it usually takes more than one to two years to effect significant weight change, and we really do not know the efficacy and safety of these drugs past the one- to two-year mark."

Only two agents, sibutramine (Meridia, Abbott Laboratories) and orlistat (Xenical, Roche), are recommended for use longer than 12 weeks, said Margaret Mill, Pharm.D., a community pharmacy practice resident at the University of Maryland School of Pharmacy in Baltimore. She explained that other agents are either not approved for the management of obesity or are not recommended for use for longer than 12 weeks. Mill pointed out that the duration of treatment is an important issue because obesity is a lifelong condition.

According to the authors of the guidelines, the choice of agent depends on the adverse-effect profile of each drug and the patient's tolerance of the side effects.

"Existing data suggest that 71% of women and 62% of men are trying to engage in weight-loss efforts at any specific time," Mill said. "Pharmacists are in a good position to help patients control their weight and make lifestyle modifications." She went on to say that pharmacists have a wide-open window of opportunity when patients ask about over-the-counter (OTC) weight loss products, because the public is often unaware of the ingredients they contain. "That presents a chance for pharmacists to engage patients in a dialogue about the importance of good nutrition and exercise," she said.

Snow agreed that pharmacists could pass along the message that obesity drugs are adjunctive to diet and lifestyle modifications.