Management of Obesity in the National Health and Nutrition Examination Survey (NHANES), 2007–2008

Contemporary treatment patterns of overweight and obesity: insights from the Mass General Brigham health care system

OBJECTIVE

The objective of this study was to describe the prevalence of obesity, obesity-related conditions (ORCs), and antiobesity medication (AOM) eligibility and prescribing practice among eligible patients in a large health care system.

METHODS

In this cross-sectional analysis of the multicenter Mass General Brigham health care system (Boston, Massachusetts) spanning 2018 to 2022, adults eligible for AOMs (BMI ≥ 30 kg/m2 or BMI 27-29.9 kg/m2 with ≥1 ORC) were identified. Among those AOM-eligible, the prevalence of prescriptions for AOMs approved for long-term weight management was evaluated.

RESULTS

Of 2,469,474 adults (mean [SD], age 53 [19] years; 57% female; BMI 28.1 [6.3] kg/m2), a total of 1,110,251 (45.0%) were eligible for AOMs. Of these, 69.4% (31.2% of overall cohort) had BMI ≥ 30 kg/m2. AOM prescription was observed in 15,214 (1.4%) of all eligible patients, with female sex, younger age, higher BMI, commercial insurance, and greater ORC burden associated with higher prevalence of AOM prescriptions. Musculoskeletal disorders (54%) were the most common ORCs, with ≥2 ORCs observed in 62% of patients. Liraglutide 3.0 mg and semaglutide 2.4 mg were the most frequently prescribed AOMs (58% and 34% of all AOMs, respectively).

CONCLUSIONS

Although nearly one-half of all patients in a large health care system were AOM-eligible by guidelines and regulatory labeling, only 1% of those who were eligible were prescribed AOMs.

Semaglutide vs Tirzepatide for Weight Loss in Adults With Overweight or Obesity

Importance

Although tirzepatide and semaglutide were shown to reduce weight in randomized clinical trials, data from head-to-head comparisons in populations with overweight or obesity are not yet available.

Objective

To compare on-treatment weight loss and rates of gastrointestinal adverse events (AEs) among adults with overweight or obesity receiving tirzepatide or semaglutide labeled for type 2 diabetes (T2D) in a clinical setting.

Design, Setting, and Participants

In this cohort study, adults with overweight or obesity receiving semaglutide or tirzepatide between May 2022 and September 2023 were identified using electronic health record (EHR) data linked to dispensing information from a collective of US health care systems. On-treatment weight outcomes through November 3, 2023, were assessed. Adults with overweight or obesity and regular care in the year before initiation, no prior glucagon-like peptide 1 receptor agonist receptor agonist use, a prescription within 60 days prior to initiation, and an available baseline weight were identified. The analysis was completed on April 3, 2024.

Exposures

Tirzepatide or semaglutide in formulations labeled for T2D, on or off label.

Main Outcomes and Measures

On-treatment weight change in a propensity score-matched population, assessed as hazard of achieving 5% or greater, 10% or greater, and 15% or greater weight loss, and percentage change in weight at 3, 6, and 12 months. Hazards of gastrointestinal AEs were compared.

Results

Among 41 222 adults meeting the study criteria (semaglutide, 32 029; tirzepatide, 9193), 18 386 remained after propensity score matching. The mean (SD) age was 52.0 (12.9) years, 12 970 were female (70.5%), 14 182 were white (77.1%), 2171 Black (11.8%), 354 Asian (1.9%), 1679 were of other or unknown race, and 9563 (52.0%) had T2D. The mean (SD) baseline weight was 110 (25.8) kg. Follow-up was ended by discontinuation for 5140 patients (55.9%) receiving tirzepatide and 4823 (52.5%) receiving semaglutide. Patients receiving tirzepatide were significantly more likely to achieve weight loss (≥5%; hazard ratio [HR], 1.76, 95% CI, 1.68, 1.84; ≥10%; HR, 2.54; 95% CI, 2.37, 2.73; and ≥15%; HR, 3.24; 95% CI, 2.91, 3.61). On-treatment changes in weight were larger for patients receiving tirzepatide at 3 months (difference, -2.4%; 95% CI -2.5% to -2.2%), 6 months (difference, -4.3%; 95% CI, -4.7% to -4.0%), and 12 months (difference, -6.9%; 95% CI, -7.9% to -5.8%). Rates of gastrointestinal AEs were similar between groups.

Conclusions and Relevance

In this population of adults with overweight or obesity, use of tirzepatide was associated with significantly greater weight loss than semaglutide. Future study is needed to understand differences in other important outcomes.

Healthcare professionals' perceptions and management of obesity & knowledge of glucagon, GLP-1, GIP receptor agonists, and dual agonists

Background

Anti-obesity medications (AOMs) have historically had limited weight-loss efficacy. However, newer glucagon-like peptide-1 receptor agonist (GLP-1 RA)-based therapies seem to be more effective, including dual agonists of GLP-1R and the glucagon receptor (GCGR) or glucose-dependent insulinotropic polypeptide receptor.

Objective

To explore healthcare professionals' (HCPs) experience in obesity treatment and their understanding of agonists of GCGR, glucose-dependent insulinotropic polypeptide (GIP) RA, and GLP-1 RA.

Methods

This cross-sectional online survey of HCPs prescribing AOMs was conducted in the United States in 2023 with a questionnaire designed to evaluate prescribing behavior and understanding of GCGR, GIP RA, and GLP-1 RA.

Results

The 785 respondents (251 primary-care physicians [PCPs], 263 endocrinologists, and 271 advanced practice providers [APPs]) reported 55% of their patients had obesity (body mass index ≥30 kg/m2 or ≥27 with weight-related complications) and recommended AOMs to 49% overall, significantly more endocrinologists (57% of patients, p < 0.0005) than PCPs (43%) or APPs (46%). The greatest barriers to treatment were medication cost/lack of insurance (mean 4.2 on 1-5 scale [no barrier-extreme barrier]), low patient engagement/adherence (3.3), and inadequate time/staff (3.1). Metformin was the type 2 diabetes (T2D) medication most commonly prescribed to treat obesity in T2D patients (92.5% of respondents). Most HCPs (65%) were very/extremely familiar with GLP-1 RA, but only 30% with GIP RA and 16% with GCGR. Most HCPs expected dual GCGR/GLP-1 RA to benefit many obesity-related conditions; however, only a minority of HCPs perceived that they would benefit non-cardiometabolic complications of obesity.

Conclusions

Among HCPs prescribing AOMs, gaps exist in the management of people living with obesity as <50% are prescribed AOMs. Barriers to treatment indicate a need to improve access to AOMs. HCPs were less familiar with GCGR or GIP RA than GLP-1 RA but expect dual GCGR/GLP-1 RA may offer additional benefits, potentially addressing treatment barriers and access. Thus, there is a need for greater education among HCPs regarding the mechanism of action and therapeutic effects of GCGR agonists, and dual GCGR/GLP-1 RA, so that the full range of obesity-related complications can be effectively treated.

Effectiveness and safety of drugs for obesity

Recent publicity around the use of new antiobesity medications (AOMs) has focused the attention of patients and healthcare providers on the role of pharmacotherapy in the treatment of obesity. Newer drug treatments have shown greater efficacy and safety compared with older drug treatments, yet access to these drug treatments is limited by providers' discomfort in prescribing, bias, and stigma around obesity, as well as by the lack of insurance coverage. Now more than ever, healthcare providers must be able to discuss the risks and benefits of the full range of antiobesity medications available to patients, and to incorporate both guideline based advice and emerging real world clinical evidence into daily clinical practice. The tremendous variability in response to antiobesity medications means that clinicians need to use a flexible approach that takes advantage of specific features of the antiobesity medication selected to provide the best option for individual patients. Future research is needed on how best to use available drug treatments in real world practice settings, the potential role of combination therapies, and the cost effectiveness of antiobesity medications. Several new drug treatments are being evaluated in ongoing clinical trials, suggesting that the future for pharmacotherapy of obesity is bright.

SICOB-endorsed national Delphi consensus on obesity treatment optimization: focus on diagnosis, pre-operative management, and weight regain/insufficient weight loss approach

PURPOSE

Overweight and obesity affects 60% of adults causing more than 1.2 million deaths across world every year. Fight against involved different specialist figures and multiple are the approved weapons. Aim of the present survey endorsed by the Italian Society of Bariatric Surgery (SICOB) is to reach a national consensus on obesity treatment optimization through a Delphi process.

METHODS

Eleven key opinion leaders (KOLs) identified 22 statements with a major need of clarification and debate. The explored pathways were: (1) Management of patient candidate to bariatric/metabolic surgery (BMS); (2) Management of patient not eligible for BMS; (3) Management of patient with short-term (2 years) weight regain (WR) or insufficient weight loss (IWL); (4) Management of the patient with medium-term (5 years) WR; and (5) Association between drugs and BMS as WR prevention. The questionnaire was distributed to 65 national experts via an online platform with anonymized results.

RESULTS

54 out of 65 invited panelists (83%) respond. Positive consensus was reached for 18/22 statements (82%); while, negative consensus (s20.4; s21.5) and no consensus (s11.5, s17) were reached for 2 statements, respectively (9%).

CONCLUSION

The Delphi results underline the importance of first-line interdisciplinary management, with large pre-treatment examination, and establish a common opinion on how to properly manage post-operative IWL/WR.

LEVEL OF EVIDENCE V

Report of expert committees.

The Relative Value of Anti-Obesity Medications Compared to Similar Therapies

Purpose

To demonstrate a need for improved health insurance coverage for anti-obesity medications (AOMs) by comparing clinical and economic benefits of obesity treatments to covered medications for selected therapeutic areas.

Methods

Using a grey literature search, we identified and prioritized therapeutic areas and treatment analogues for comparison to obesity. A targeted literature review identified clinical and economic outcomes research across the therapeutic area analogues. Associated comorbidities, clinical evidence, indirect costs (ie, absenteeism and productivity loss), and direct medical costs were evaluated to determine the relative value of treating obesity.

Results

Four therapeutic areas/treatment analogues were selected for comparison to obesity: smoking cessation (varenicline), daytime sleepiness (modafinil), migraines (erenumab), and fibromyalgia (pregabalin). Obesity was associated with 17 comorbidities, more than migraine (9), smoking (8), daytime sleepiness (5), and fibromyalgia (2). Economic burden was greatest for obesity, followed by smoking, with yearly indirect and direct medical costs totaling $676 and $345 billion, respectively. AOMs resulted in cost savings of $2586 in direct medical costs per patient per year (PPPY), greater than that for varenicline at $930 PPPY, modafinil at $1045 PPPY, and erenumab at $468 PPPY; pregabalin utilization increased costs by $924 PPPY. AOMs were covered by 10-16% of United States health insurance plans, compared to 45-59% for the four comparators.

Conclusion

Compared to four therapeutic analogues, obesity represented the highest economic burden and was associated with more comorbidities. AOMs provide greater cost savings compared to selected analogues. However, AOMs have limited formulary coverage. Improved coverage of AOMs may increase access to these treatments and may help address the clinical and economic burden associated with obesity and its comorbidities.

Medical and Surgical Treatment of Obesity

During the past decade, several effective antiobesity medications and devices have been developed. In addition, new information regarding the mechanism of action, benefits, and long-term efficacy of bariatric surgery continues to emerge. More than 90% of patients who qualify for therapy for obesity remain untreated. This article aims to provide an overview of the indications and efficacy of currently available medical and surgical therapies for obesity, along with a look toward promising therapies on the horizon.

Anti-obesity Medication Use Among Adults with Overweight and Obesity in the United States: 2015-2018

OBJECTIVE

To estimate utilization of FDA-approved prescription anti-obesity medications (AOMs) and identify factors associated with AOM use in the United States.

METHODS

Respondents >18 years-old meeting AOM eligibility criteria in 2015-2016 and 2017-2018 National Health and Nutrition Examination Survey (NHANES) and 2016 Medical Expenditure Panel Survey (MEPS) were included in the study. AOM eligibility was defined as having a body mass index (BMI) >30 kg/m², or a BMI between 27 to 29.9 kg/m² and at least one obesity-related comorbidity. Demographic, socioeconomic, and clinical characteristics, economic outcomes and health-related quality of life were summarized and compared between AOM users and non-users. Multivariable logistic regression was used to identify factors associated with AOM use.

RESULTS

Only 0.80% of eligible adults reported use of AOMs in the past 30 days in 2015-2016 and 2017-2018 NHANES. A greater proportion of current AOM users previously tried dietary changes compared to non-users. They also reported an average weight loss of 6.8 lbs. (3.1 kg) over the previous year compared to a 3.3 lbs. (1.5 kg) gain among non-users. Total healthcare costs trended higher among AOM users, driven mostly by higher outpatient healthcare costs. A BMI ≥30 kg/m², depression, dyslipidemia, and infertility predicted AOM use, whereas Medicare and being at risk of sleep apnea were associated with lower odds of AOM use.

CONCLUSION

Despite availability of newer AOMs and inclusion of AOMs in medical treatment guidelines, AOM utilization remains low. This may reflect under-prescribing of and/or restricted patient access to approved evidence-based pharmacotherapy for obesity.

Metabolomic profiling identifies complex lipid species and amino acid analogues associated with response to weight loss interventions

Obesity is an epidemic internationally. While weight loss interventions are efficacious, they are compounded by heterogeneity with regards to clinically relevant metabolic responses. Thus, we sought to identify metabolic biomarkers that are associated with beneficial metabolic changes to weight loss and which distinguish individuals with obesity who would most benefit from a given type of intervention. Liquid chromatography mass spectrometry-based profiling was used to measure 765 metabolites in baseline plasma from three different weight loss studies: WLM (behavioral intervention, N = 443), STRRIDE-PD (exercise intervention, N = 163), and CBD (surgical cohort, N = 125). The primary outcome was percent change in insulin resistance (as measured by the Homeostatic Model Assessment of Insulin Resistance [%ΔHOMA-IR]) over the intervention. Overall, 92 individual metabolites were associated with %ΔHOMA-IR after adjustment for multiple comparisons. Concordantly, the most significant metabolites were triacylglycerols (TAGs; p = 2.3e-5) and diacylglycerols (DAGs; p = 1.6e-4), with higher baseline TAG and DAG levels associated with a greater improvement in insulin resistance with weight loss. In tests of heterogeneity, 50 metabolites changed differently between weight loss interventions; we found amino acids, peptides, and their analogues to be most significant (4.7e-3) in this category. Our results highlight novel metabolic pathways associated with heterogeneity in response to weight loss interventions, and related biomarkers which could be used in future studies of personalized approaches to weight loss interventions.

Simulating the Fiscal Impact of Anti-Obesity Medications as an Obesity Reduction Strategy

While substantial public health investment in anti-smoking initiatives has had demonstrated benefits on health and fiscal outcomes, similar investment in reducing obesity has not been undertaken, despite the substantial burden obesity places on society. Anti-obesity medications (AOMs) are poorly prescribed despite evidence that weight loss is not sustained using other strategies alone.

We used a simulation model to estimate the potential impact of 100% uptake of AOMs on Medicare and Medicaid spending, disability payments, and taxes collected relative to status quo with negligible AOM use. Relative to status quo, AOM use simulation would result in Medicare and Medicaid savings of $231.5 billion and $188.8 billion respectively over 75 years. Government tax revenues would increase by $452.8 billion. Overall, the net benefit would be $746.6 billion. Anti-smoking efforts have had substantial benefits for society. A similar investment in obesity reduction, including broad use of AOMs, should be considered.

Novel plasma biomarkers improve discrimination of metabolic health independent of weight

We sought to determine if novel plasma biomarkers improve traditionally defined metabolic health (MH) in predicting risk of cardiovascular disease (CVD) events irrespective of weight. Poor MH was defined in CATHGEN biorepository participants (n > 9300), a follow-up cohort (> 5600 days) comprising participants undergoing evaluation for possible ischemic heart disease. Lipoprotein subparticles, lipoprotein-insulin resistance (LP-IR), and GlycA were measured using NMR spectroscopy (n = 8385), while acylcarnitines and amino acids were measured using flow-injection, tandem mass spectrometry (n = 3592). Multivariable Cox proportional hazards models determined association of poor MH and plasma biomarkers with time-to-all-cause mortality or incident myocardial infarction. Low-density lipoprotein particle size and high-density lipoprotein, small and medium particle size (HMSP), GlycA, LP-IR, short-chain dicarboxylacylcarnitines (SCDA), and branched-chain amino acid plasma biomarkers were independently associated with CVD events after adjustment for traditionally defined MH in the overall cohort (p = 3.3 × 10-4-3.6 × 10-123), as well as within most of the individual BMI categories (p = 8.1 × 10-3-1.4 × 10-49). LP-IR, GlycA, HMSP, and SCDA improved metrics of model fit analyses beyond that of traditionally defined MH. We found that LP-IR, GlycA, HMSP, and SCDA improve traditionally defined MH models in prediction of adverse CVD events irrespective of BMI.

Patient initiation and maintenance of GLP-1 RAs for treatment of obesity: a narrative review and practical considerations for primary care providers

Obesity is a chronic, relapsing metabolic disease, linked to a number of health risks and serious complications. Although highly prevalent in adults in the United States, it is underdiagnosed and untreated. Primary care providers (PCPs) are uniquely poised to diagnose and treat patients with obesity, using a selection of treatment strategies including lifestyle modifications and pharmacotherapies. As a physiological regulator of appetite and energy intake, the glucagon-like peptide-1 receptor agonist (GLP-1 RA) liraglutide 3.0 mg is approved for chronic weight management in individuals with overweight (pre-obesity) or obesity. In this review, we provide an overview of the clinical data supporting the use of liraglutide 3.0 mg, as well as practical advice for PCPs on the initiation and maintenance of treatment over the long term. This also covers the management of side effects and how to manage patient expectations over time.

Pharmacotherapy for Obesity-Trends Using a Population Level National Database

BACKGROUND

Despite the growing trend of obesity, the utilization of anti-obesity therapeutic interventions is not robust in the USA. We aimed to analyze the trends of anti-obesity pharmacotherapy using a population level database.

METHODS

We used an electronic health record-derived database (Explorys, IBM Watson Health) to identify adults with obesity (body mass index ≥ 30 kg/m²), 2010-2019. Annual rates of anti-obesity pharmacotherapy were analyzed. To assess post-bariatric utilization of these medications, the trend of adults with morbid obesity (BMI ≥ 40 kg/m ²) who were newly started on anti-obesity medications after sleeve gastrectomy was also analyzed.

RESULTS

Among 11,195,020 adults with obesity, 274,160 (2.4%) were prescribed anti-obesity medications during the study period with an increase from 1.1% in 2010 to 2.9% in 2019 (p < 0.0001). A total of 900 (3.5%) of those with morbid obesity were started on weight loss medications within 5 years of sleeve gastrectomy. Women [odds ratio (OR) 3.57, 95% confidence interval (CI) 3.51-3.58], individuals under 50 years (OR 1.59, CI 1.57-1.60), non-Hispanics (OR 1.12, 1.10-1.14, p < 0.0001), African Americans (OR 1.18, CI 1.16-1.19), Medicaid (OR 1.70, CI 1.67-1.73), and commercial insurance holders (OR 2.46, 2.43-2.49) were more likely to receive anti-obesity pharmacotherapy, p < 0.001 for all comparisons.

CONCLUSION

There has been a modest increase in the prevalence of anti-obesity medications in the last 10 years, but they remain significantly underutilized. Further studies addressing the barriers to anti-obesity pharmacotherapy might help in increasing the utilization of these medications among adults with obesity.

Evaluation of Obesity Management Recorded in Electronic Clinical History: A Cohort Study

BACKGROUND

The prevalence of obesity is increasing worldwide. Because of their close proximity to the population, primary care physicians and nurses are in a unique position to motivate and advise patients with obesity on a healthy diet and increased physical activity. Drawing from information recorded in electronic clinical records, we evaluated how the general recommendations included in obesity guidelines are being implemented in routine clinical practice.

METHODS

This study drew from the following data from a cohort of 209 patients with obesity that attended primary care consultations: electronic clinical records, body mass index (BMI), waist circumference (WC), cardiovascular risk factors, comorbidities and whether their health professional documented compliance with the recommendations of the evidence-based obesity guidelines in their electronic history.

RESULTS

Only 25.4% of the clinical records met all the criteria established in the therapeutic guidelines regarding diet prescription, 1.4% for physical activity and 1.5% for behavioral change activities. The patients whose records mentioned diet prescription and physical activity and who received follow-up consultations for both factors had lower average BMI and WC, although this relationship was not significant after adjusting for baseline.

CONCLUSIONS

We found that only a small number of records in the electronic clinical histories followed the evidence-based obesity guidelines. Recording dietetic prescription and physical exercise in the patient's clinical record is associated with better control of obesity.

The Societal Value of Broader Access to Antiobesity Medications

OBJECTIVE

Obesity and its complications place an enormous burden on society. Yet antiobesity medications (AOM) are prescribed to only 2% of the eligible population, even though few individuals can sustain weight loss using other strategies alone. This study estimated the societal value of greater access to AOM.

METHODS

By using a well-established simulation model (The Health Economics Medical Innovation Simulation), the societal value of AOM for the cohort of Americans aged ≥ 25 years in 2019 was quantified. Four scenarios with differential uptake among the eligible population (15% and 30%) were modeled, with efficacy from current and next-generation AOM. Societal value was measured as monetized quality of life, productivity gains, and savings in medical spending, subtracting the costs of AOM.

RESULTS

For the 217 million Americans aged ≥ 25 years, AOM generated $1.2 trillion in lifetime societal value under a conservative scenario (15% annual uptake using currently available AOM). The introduction of next-generation AOM increased societal value to $1.9 to $2.5 trillion, depending on uptake. Finally, societal value was higher for younger individuals and Black and Hispanic individuals compared with White individuals.

CONCLUSIONS

This study suggests that AOM provide substantial gains to patients and society. Policies promoting broader clinical access to and use of AOM warrant consideration to reach national goals to reduce obesity.

Antiobesity Medication Use in 2.2 Million Adults Across Eight Large Health Care Organizations: 2009-2015

OBJECTIVE

The aim of this study was to examine the prescribing patterns and use of antiobesity medications in a large cohort of patients using data from electronic health records.

METHODS

Pharmacy- and patient-level electronic health record data were obtained on 2,248,407 adults eligible for weight-loss medications from eight geographically dispersed health care organizations.

RESULTS

A total of 29,964 patients (1.3% of total cohort) filled at least one weight-loss medication prescription. This cohort was 82.3% female, with median age 44.9 years and median BMI 37.2 kg/m2 . Phentermine accounted for 76.6% of all prescriptions, with 51.7% of prescriptions being filled for ≥ 120 days and 33.8% filled for ≥ 360 days. There was an increase of 32.9% in medication days for all medications in 2015 compared with 2009. Higher prescription rates were observed in women, black patients, and patients in higher BMI classes. Of 3,919 providers who wrote at least one filled prescription, 23.8% (n = 863) were "frequent prescribers" who wrote 89.6% of all filled prescriptions.

CONCLUSIONS

Weight-loss medications are rarely prescribed to eligible patients. Phentermine accounted for > 75% of all medication days, with a majority of patients filling it for more than 4 months. Less than one-quarter of prescribing providers accounted for approximately 90% of all prescriptions.

Patient Characteristics Associated with Receipt of Prescription Weight-Management Medications Among Veterans Participating in MOVE!

OBJECTIVE

Weight-management medications (WMM) are recommended for the treatment of obesity. This study examined characteristics associated with initial receipt of WMM among eligible veterans in the first year following enrollment in the Veterans Health Administration (VHA) MOVE! behavioral weight-management program.

METHODS

We conducted a retrospective cohort study of VHA patients with obesity or overweight and obesity-related comorbidities who enrolled in MOVE! from October 2013 to September 2016 (N = 153,939). Multivariable logistic regression models estimated predictors of having a filled prescription for WMM and for orlistat.

RESULTS

A total of 1.1% of these veterans received WMM. The most common WMM included orlistat (70.4%), phentermine/topiramate (11.2%), and bupropion/naltrexone (9.7%). Female sex, higher BMI, obstructive sleep apnea, osteoarthritis, depression, lower back pain, and alcohol abuse were associated with greater odds of use of WMM, whereas age over 65 years, Hispanic ethnicity, and required co-payments were associated with lower odds. Among patients receiving WMM, older age, black race, female sex, higher BMI, cardiovascular disease, lower back pain, and congestive heart failure were associated with use of orlistat versus any other WMM.

CONCLUSIONS

Of patients engaged in MOVE! in the VHA, 1.1% received WMM. WMM are underutilized among veterans. Additional research is needed to understand barriers to incorporating WMM into comprehensive obesity treatment plans.

A Randomized, Double-Blind, Placebo-Controlled Study of Gelesis100: A Novel Nonsystemic Oral Hydrogel for Weight Loss

OBJECTIVE

This study aims to assess the efficacy and safety of Gelesis100, a novel, nonsystemic, superabsorbent hydrogel to treat overweight or obesity.

METHODS

The Gelesis Loss Of Weight (GLOW) study was a 24-week, multicenter, randomized, double-blind, placebo-controlled study in patients with BMI ≥  27 and ≤ 40 kg/m2 and fasting plasma glucose ≥ 90 and ≤ 145 mg/dL. The co-primary end points were placebo-adjusted weight loss (superiority and 3% margin super-superiority) and at least 35% of patients in the Gelesis100 group achieving ≥ 5% weight loss.

RESULTS

Gelesis100 treatment caused greater weight loss over placebo (6.4% vs. 4.4%, P = 0.0007), achieving 2.1% superiority but not 3% super-superiority. Importantly, 59% of Gelesis100-treated patients achieved weight loss of ≥ 5%, and 27% achieved ≥ 10% versus 42% and 15% in the placebo group, respectively. Gelesis100-treated patients had twice the odds of achieving ≥ 5% and ≥ 10% weight loss versus placebo (adjusted OR: 2.0, P = 0.0008; OR: 2.1, P = 0.0107, respectively), with 5% responders having a mean weight loss of 10.2%. Patients with prediabetes or drug-naive type 2 diabetes had six times the odds of achieving ≥ 10% weight loss. Gelesis100 treatment had no apparent increased safety risks.

CONCLUSIONS

Gelesis100 is a promising new nonsystemic therapy for overweight and obesity with a highly desirable safety and tolerability profile.

Persistence of newer anti-obesity medications in a real-world setting

AIMS

Evaluate real-world data on persistence with anti-obesity medications (AOMs) and explore associated patient factors.

METHODS

Truven Health MarketScan® data were analyzed to evaluate utilization of AOMs approved for long-term use between 4/2015 and 3/2016. Kaplan-Meier survival analyses were used to evaluate treatment persistence. A multivariate analysis was performed to identify associations between persistence and relevant factors.

RESULTS

In total, 26,522 adult patients were identified as newly prescribed naltrexone/bupropion (44.0%, mean age 47.1, 80.5% female), lorcaserin (24.8%, 48.5, 79.3%), phentermine/topiramate extended release (15.8%, 46.7, 82.2%) or liraglutide 3.0 mg (15.4%, 46.9, 72.4%). At 6 months, 41.8% of patients were still on liraglutide 3.0 mg, compared to 15.9% lorcaserin (p < 0.001), 18.1% naltrexone/bupropion (p < 0.001), and 27.3% phentermine/topiramate (p < 0.001). After adjusting for baseline factors, patients on liraglutide 3.0 mg had significantly lower risk of discontinuation compared to those on lorcaserin (HR = 0.46, p < 0.0001), naltrexone/bupropion (HR = 0.48, p < 0.0001), and phentermine/topiramate (HR = 0.64, p < 0.0001) over the course of follow-up (mean follow-up duration, 342-427 days). Older age, male gender, having hyperlipidemia, and no prior phentermine use were associated with higher persistence. Over 95% of study patients had commercial insurance.

CONCLUSIONS

In a real-world setting, patients on liraglutide 3.0 mg had the highest persistence rate of the four AOMs studied.

Weight Loss Strategies for Treatment of Obesity: Lifestyle Management and Pharmacotherapy

Obesity is one of the most serious and prevalent non-communicable diseases of the twenty-first century. It is also a patient-centered condition in which affected individuals seek treatment through a variety of commercial, medical and surgical approaches. Considering obesity as a chronic medical disease state helps to frame the concept of using a three-stepped intensification of care approach to weight management. As a foundation, all patients should be counseled on evidence-based lifestyle approaches that include diet, physical activity and behavior change therapies. At the second tier, four new pharmacological agents, lorcaserin, phentermine/topiramate, naltrexone/bupropion and liraglutide have been approved since 2012 as adjuncts to lifestyle modification. The third step, bariatric surgery, has been demonstrated to be the most effective and long-term treatment for individuals with severe obesity or moderate obesity complicated by co-morbid conditions that is not responsive to non-surgical approaches. By using a medical model, clinicians can provide more proactive and effective treatments in assisting their patients with weight loss.

Cardiometabolic Effects of Anti-obesity Pharmacotherapy

PURPOSE OF REVIEW

We review recent studies discussing the impact of pharmacologic agents for weight loss on clinical cardiovascular events, as well as cardiometabolic risk factors.

RECENT FINDINGS

Pharmacotherapy with current FDA-approved medications for weight loss can significantly improve known risk factors for the development of cardiovascular disease such as hypertension, hyperlipidemia, insulin resistance, inflammatory biomarkers, and the quantity of visceral fat, as well as non-alcoholic fatty liver disease. However, data regarding the actual reduction in clinical cardiovascular events with the use of weight loss medications is scarce. Pharmacotherapy for weight loss may have additional benefit in optimizing patient's cardiometabolic comorbidities and improving their clinical cardiovascular outcomes, but each drug should be carefully selected based upon individual patient characteristics.

Introduction: The State of Obesity in 2017

Obesity continues to be a major national and global health challenge and a risk factor for an expanding set of chronic diseases. In 2015, high body mass index contributed to 4.0 million deaths globally, which represented 7.1% of the deaths from any cause. Obesity is now regarded as a disease, and multiple health care societies have begun to tackle obesity as a discrete target for assessment and treatment that is supported by several position statements and guidelines. Nonetheless, a perception and treatment gap continues to exist between health care providers and patients regarding the provision of obesity care.

Low adoption of weight loss medications: A comparison of prescribing patterns of antiobesity pharmacotherapies and SGLT2s

OBJECTIVE

To characterize the adoption of antiobesity pharmacotherapies, as compared with that of the newest antidiabetes pharmacotherapy, subtype 2 sodium-glucose transport protein inhibitors (SGLT2s), among prescribers in the United States.

METHODS

A retrospective analysis of 2012 to 2015 data extracted from the IMS Health National Prescription Audit™ and Xponent™ assessed adoption rates of antiobesity pharmacotherapies and SGLT2s.

RESULTS

The number of dispensed antidiabetes prescriptions was 15 times the number of dispensed antiobesity prescriptions. The antiobesity market share was: 74.0% phentermine, 18.6% new antiobesity pharmacotherapies. The mean increase in prescriptions/month were: 25,259 for SGLT2s, 5,154 for new antiobesity pharmacotherapies, and 2,718 for phentermine. Medical specialties prescribing the majority of the analysis medications were Family Medicine/General Practice and Internal Medicine. Endocrinology had the highest prevalence of prescribers of any subspecialty.

CONCLUSIONS

The adoption rate of SGLT2s was nearly exponential, while the adoption rate of new antiobesity pharmacotherapies was linear. Considering the relative prevalence of obesity to diabetes and that obesity is a major cause of diabetes, these results are paradoxical and suggest systematic barriers against the prescribing of antiobesity pharmacotherapies. The under-prescribing of antiobesity pharmacotherapies is widely acknowledged, but this is the first prescription data of these new medications to demonstrate its extent in the United States.

Characteristics of patients potentially eligible for pharmacotherapy for weight loss in primary care practice in the United States

Objective

To describe the characteristics of real‐world patients potentially eligible for adjunctive pharmacotherapy for weight loss.

Methods

Patients from the GE Centricity electronic medical record database were selected if they had body mass index (BMI) ≥30 or ≥27 to <30 kg m⁻² with ≥1 obesity‐associated comorbidity (hypertension, dyslipidemia, or type 2 diabetes) from 2002–2011; were aged ≥18 years and had ≥12 months of continuous enrollment before and after the date of first eligible BMI recorded (index date). Descriptive statistics and logistic regression were used for analysis.

Results

Of the 1,835,541 patients with overweight or obesity included, comorbidities were common (hypertension [55.4%], dyslipidemia [36.1%] and type 2 diabetes [13.4%]). The percentage of patients who received pharmacotherapy for weight loss was 0.7% within 12 months after the index date. Patients who received pharmacotherapy had higher BMI (median, 33.6 vs. 31.3 kg m⁻²), were younger (median, 42 vs. 52 years), primarily women (84.3 vs. 58.2%), commercially insured (70.1 vs. 50.4%) and had more frequent use of antidepressants (30.8 vs. 14.1%) and non‐steroidal anti‐inflammatory drugs (21.7 vs. 12.0%) than those who did not at baseline (all P values < 0.0001).

Conclusions

Few eligible patients received pharmacotherapy for weight loss. Patients who received pharmacotherapy tended to be heavier, younger, female, commercially insured, and used more antidepressants and non‐steroidal anti‐inflammatory drugs.

Role of gastrointestinal hormones in feeding behavior and obesity treatment

Food intake regulation is generally evaluated by many aspects consisting of complex mechanisms, including homeostatic regulatory mechanism, which is based on negative feedback, and hedonic regulatory mechanism, which is driven by a reward system. One important aspect of food intake regulation is the peripheral hormones that are secreted from the gastrointestinal tract. These hormones are secreted from enteroendocrine cells as feedback to nutrient and energy intake, and will communicate with the brain directly or via the vagus nerve. Gastrointestinal hormones are very crucial in maintaining a steady body weight, despite variations in nutrient intake and energy expenditure. In this review, we provide an overview of the regulation of feeding behavior by gut hormones, and its role in obesity treatments.

Self-weighing in weight management: a systematic literature review

OBJECTIVE

Regular self-weighing, which in this article is defined as weighing oneself regularly over a period of time (e.g., daily, weekly), is recommended as a weight loss strategy. However, the published literature lacks a review of the recent evidence provided by prospective, longitudinal studies. Moreover, no paper has reviewed the psychological effects of self-weighing. Therefore, the objective is to review the literature related to longitudinal associations between self-weighing and weight change as well as the psychological outcomes.

METHODS

Electronic literature searches in PubMed, Ovid PsycINFO, and Ebscohost CINAHL were conducted. Keywords included overweight, obesity, self-weighing, etc. Inclusion criteria included trials that were published in the past 25 years in English; participants were adults seeking weight loss treatment; results were based on longitudinal data.

RESULTS

The results (N=17 studies) revealed that regular self-weighing was associated with more weight loss and not with adverse psychological outcomes (e.g., depression, anxiety). Findings demonstrated that the effect sizes of association between self-weighing and weight change varied across studies and also that the reported frequency of self-weighing varied across studies.

CONCLUSIONS

The findings from prospective, longitudinal studies provide evidence that regular self-weighing has been associated with weight loss and not with negative psychological outcomes.

Safety of antiobesity drugs

Obesity is a major health problem worldwide. Although diet and physical activity are crucial in the management of obesity, the long-term success rate is low. Therefore antiobesity drugs are of great interest, especially when lifestyle modification has failed. As obesity is not an immediate life-threatening disease, these drugs are required to be safe. Antiobesity drugs that have been developed so far have limited efficacies and considerable adverse effects affecting tolerability and safety. Therefore, most antiobesity drugs have been withdrawn. Fenfluramine and dexfenfluramine were withdrawn because of the potential damage to heart valves. Sibutramine was associated with an increase in major adverse cardiovascular events in the Sibutramine Cardiovascular Outcomes (SCOUT) trial and it was withdrawn from the market in 2010. Rimonabant was withdrawn because of significant psychiatric adverse effects. Orlistat was approved in Europe and the United States for long-term treatment of obesity, but many patients cannot tolerate its gastrointestinal side effects. Phentermine and diethylpropion can only be used for less than 12 weeks because the long-term safety of these drugs is unknown. Ephedrine and caffeine are natural substances but the effects on weight reduction are modest. As a result there is a huge unmet need for effective and safe antiobesity drugs. Recently lorcaserin and topiramate plus phentermine have been approved for the treatment of obesity but long-term safety data are lacking.

Exercise training and cardiometabolic diseases: focus on the vascular system

The regular practice of physical activity is a well-recommended strategy for the prevention and treatment of several cardiovascular and metabolic diseases. Physical exercise prevents the progression of vascular diseases and reduces cardiovascular morbidity and mortality. Exercise training also ameliorates vascular changes including endothelial dysfunction and arterial remodeling and stiffness, usually present in type 2 diabetes, obesity, hypertension and metabolic syndrome. Common to these diseases is excessive oxidative stress, which plays an important role in the processes underlying vascular changes. At the vascular level, exercise training improves the redox state and consequently NO availability. Moreover, growing evidence indicates that other mediators such as prostanoids might be involved in the beneficial effects of exercise. The purpose of this review is to update recent findings describing the adaptation response induced by exercise in cardiovascular and metabolic diseases, focusing more specifically on the beneficial effects of exercise in the vasculature and the underlying mechanisms.

Weight loss strategies for treatment of obesity

Obesity is one of the most serious and prevalent non-communicable diseases of the 21st century. It is also a patient-centered condition in which affected individuals seek treatment through a variety of commercial, medical and surgical approaches. Considering obesity as a chronic medical disease state helps to frame the concept of using a three-stepped intensification of care approach to weight management. As a foundation, all patients should be counseled on evidence-based lifestyle approaches that include diet, physical activity and behavior change therapies. At the second tier, two new pharmacological agents, phentermine-topiramate and lorcaserin, were approved in 2012 as adjuncts to lifestyle modification. The third step, bariatric surgery, has been demonstrated to be the most effective and long-term treatment for individuals with severe obesity or moderate obesity complicated by comorbid conditions that is not responsive to non-surgical approaches. By using a medical model, clinicians can provide more proactive and effective treatments in assisting their patients with weight loss.

Adiposopathy and thyroid disease: tracing the pathway to cardiovascular risk

Adiposopathy, defined as functionally disturbed adipose tissue mainly composed of large adipocytes and induced by chronic excess of food intake, has been associated with immune, metabolic and endocrine derangements promoting inflammation and, eventually, cardiovascular disease. Adiposopathy may positively influence thyrotropin-stimulating hormone, by raising leptin levels, and triggering autoimmunity. In this regard, it is hypothesized that the increased thyrotropin-stimulating hormone is independent of the negative regulation of the thyroid hormone, thereby constituting a secondary phenomenon and not a causal effect. Replacement therapy with thyroid hormones should therefore be applied following strict individualized consideration. Leptin is involved in the immune response and neuroendocrine appetite regulation, while leptin resistance may further promote autoimmune disease. The lipid derangement in adiposopathy may be aggravated in the presence of hypothyroidism and thus considerably augment cardiovascular risk. Lifestyle-modification counselling, including low-fat dietary intake and regular physical exercise, is today the cornerstone of adiposopathy treatment. Meanwhile, new drug formulations, such as leptin and leptin analogs, 5-HT2C-receptor agonist, and potent thyromimetics, currently comprise a promising armamentarium against adiposity and adiposopathy.