Weight Loss: Helping Your Overweight and Obese Patients

Full update May 2021

--Below are recommendations and resources to help your patients who need to lose weight.--

Goal

Suggested Strategies or Resources

Assess patients and document properly.

Measure height, weight, and body mass index (BMI) at least annually in adults.1,3

Identify adults who may be at increased risk of cardiovascular disease and mortality due to weight.1,3

  • overweight (BMI 25 to 29.9 kg/m2)
  • obese (BMI ≥30 kg/m2)

Use risk assessment tools at recommended time intervals, such as every three to five years for overweight or obese adults with type 2 diabetes patients.1 Examples include:

Screen children and adolescents six years and older for obesity.11

Recommend calorie intake reduction for adults.

Recommend a diet with reduced calorie intake for overweight or obese individuals to lose about one to 1.5 pounds per week, such as:3

  • 1,200 to 1,500 kcal/day for women.
  • 1,500 to 1,800 kcal/day for men.

Access sample reduced-calorie daily menus at http://www.nhlbi.nih.gov/health/educational/lose_wt/eat/menus.htm.

Consider patient preferences and health status with regard to diet.3 Keep in mind “named” diets such as Zone, Nutrisystem, Atkins, etc., seem to produce similar weight loss.4,6 Those with more structured interventions such as Jenny Craig may show slightly better results for the first six months.4,6-8

A large, consistent body of research supports the Mediterranean diet’s cardiovascular benefits.12 For a short description of the Mediterranean diet, see https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/mediterranean-diet.

Consider referral to a nutrition professional for counseling.3

Recommend increasing physical activity as appropriate.

Recommend physical activity to contribute to weight loss.5

  • For adults, start with 30 to 45 minutes of moderate-intensity physical activity (e.g., brisk walking, water aerobics, light bicycling) three to five days a week.
    • Set a goal to increase to at least 30 minutes of moderate-intensity physical activity on most (preferably all) days of the week.
  • Children should get at least 60 minutes of physical activity each day.13

Employ behavior therapy.

Recommend participation in a comprehensive lifestyle program (e.g., diet; exercise; and counseling, education, or support) for at least six months for patients who are overweight or obese.1,3 This is also the preferred option for overweight and obese children and youth.9,11

  • The Noom app shows promise as an alternative to the in-person education and support component in adults.14

Recommend long-term participation in a weight-maintenance program for those who have lost weight.3,5

Treat with medications that can help with weight loss when appropriate.

Use pharmacotherapy in addition to behavioral modifications when possible for adults with BMI ≥27 kg/m2 with a comorbidity (e.g., dyslipidemia, hypertension, type 2 diabetes) or BMI >30 kg/m2.2 (Note that Canadian guidelines recommend against the routine use of pharmacotherapy for weight loss.1)

Although orlistat and liraglutide, are approved for use in adolescents, pharmacotherapy is not the preferred method of weight loss in children.9,11 Metformin (off-label use) has a small benefit that may not be clinically significant.11

Choose drug therapy based on side effects, comorbid conditions, and cost.2 See our chart, Weight Loss Products, for dosing, efficacy, cost, and other considerations for use.

Monitor patients using weight loss meds for safety and efficacy monthly for the first three months then every three months thereafter.2

Use drug therapy on a chronic basis to sustain weight loss and control comorbidities such as type 2 diabetes and hypertension.2

Discontinue treatment if the patient doesn’t lose at least ~5% of body weight after 12 weeks on a maximum dose. Consider an alternative medication or treatment.2 (Canada, Saxenda [liraglutide]: consider an alternative if pediatric patients do not have at least a 1% reduction in BMI after 12 weeks.15)

Counsel patients regarding the use of supplements for weight loss, such as about potential side effects (e.g., increased blood pressure and heart rate) from ephedrine and other stimulant-containing supplements, as well as the lack of proof for efficacy for many supplements marketed for weight loss (e.g., garcinia, raspberry ketone, green coffee extract).

  • See our Natural Medicines Comprehensive Database for details on specific supplements, and see Weight Loss Supplements, part of our Clinical Management Series.

Steer away from drugs that cause weight gain, if possible.

For overweight or obese patients with type 2 diabetes, consider diabetes medications that are either weight neutral or that lead to weight loss.2 See our charts, Drugs for Type 2 Diabetes (U.S.) Stepwise Treatment of Type 2 Diabetes (Canada), for options.

Access our chart, Drugs Associated With Weight Gain, for more about drugs that can cause weight gain, along with reported weight gain and possible alternatives.

Support patients who have had bariatric surgery.

Bariatric surgery can be considered for certain individuals with BMI ≥35 kg/m2 with an obesity-related comorbidity or BMI >40 kg/m2.2,3

Access our chart, Bariatric Surgery and Medication Use, to help care for these patients.

Encourage patients by sharing information.

Make overweight and obese individuals/caregivers aware of the health benefits of weight loss.

  • Sustained weight loss of around 5% of body weight can lead to improvements in blood pressure, blood glucose, and lipids, as well as a reduced need for some medications such as statins and diabetes meds.1,3
  • Weight loss may help improve physical functioning and ability to increase physical activity.2

Advise adults that greater BMI and waist circumference are associated with increased risk of cardiovascular disease, type 2 diabetes, and all-cause mortality.1,3

Advise caregivers that in children, excess body fat is associated with adulthood obesity. Childhood obesity is associated with high blood pressure, dyslipidemia, sleep apnea, asthma, orthopedic problems, polycystic ovary disease, early maturation, and fatty liver.11

The 5-2-1-0 mnemonic (5 or more fruit/vegetable servings, ≤2 hours’ screen time, ≥1 hour of physical activity, and 0 sugary drinks/day) can be used to promote healthy lifestyle choices to children and families.10

Access more information about healthy weight loss and the benefits of weight loss.

Help patients keep track of information to meet their goals.

To find information about calorie content of foods and track caloric intake:

To track physical activity and calorie intake, suggest a website or app such as MyFitnessPal (https://www.myfitnesspal.com/)

For patients who prefer manual logs for diet and exercise:

The U.S. Department of Health and Human Services (DHHS) has an interactive weekly activity planner “Move Your Way,” available at https://health.gov/moveyourway/activity-planner/activities.

 

References

  1. Brauer P, Gorber SC, Shaw E, et al. Recommendations for prevention of weight gain and use of behavioural and pharmacologic interventions to manage overweight and obesity in adults in primary care. CMAJ 2015;187:184-95.
  2. Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2015;100:342-62.
  3. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and The Obesity Society. J Am Coll Cardiol 2014;63(25 Pt B):2985-3023.
  4. Ge L, Sadeghirad B, Ball GDC, et al. Comparison of dietary macronutrient patterns of 14 popular named dietary programmes for weight and cardiovascular risk factor reduction in adults: systematic review and network meta-analysis of randomised trials. BMJ 2020;369:m696. [Erratum: 2020;370:m3095].
  5. National Institutes of Health. Aim for a healthy weight. http://www.nhlbi.nih.gov/health/educational/lose_wt/recommen.htm. (Accessed April 19, 2021).
  6. Attalah R, Filion KB, Wakil SM, et al. Long-term effects of 4 popular diets on weight loss and cardiovascular risk factors: a systematic review of randomized controlled trials. Circ Cardiovasc Qual Outcomes 2014;7:815-27.
  7. Gudzune KA, Doshi RS, Mehta AK, et al. Efficacy of commercial weight-loss programs: an updated systematic review. Ann Intern Med 2015;162:501-12.
  8. Wee CC. The role of commercial weight-loss programs. Ann Intern Med 2015;162:522-3.
  9. Canadian Task Force on Preventive Health Care. Recommendations for growth monitoring, prevention and management of overweight and obesity in children and youth in primary care. CMAJ 2015;187:411-21.
  10. Rogers VW, Motyka E. 5-2-1-0 goes to school: a pilot project testing the feasibility of schools adopting and delivering healthy messages during the school day. Pediatrics 2009;123(Suppl 5):S272-6.
  11. U.S. Preventive Services Task Force. Obesity in children and adolescents: screening. June 20, 2017. https://uspreventiveservicestaskforce.org/uspstf/recommendation/obesity-in-children-and-adolescents-screening. (Accessed April 19, 2021).
  12. Martinez-Gonzalez MA, Gea A, Ruiz-Canela M. The Mediterranean diet and cardiovascular health. Circ Res 2019;124:779-98.
  13. National Institutes of Health. How much physical activity should your family get? Last updated February 13, 2013. https://www.nhlbi.nih.gov/health/educational/wecan/get-active/physical-activity-guidelines.htm. (Accessed April 20, 2021).
  14. Toro-Ramos T, Michaelides A, Anton M, et al. Mobile delivery of the Diabetes Prevention Program in people with prediabetes: randomized controlled trial. JMIR Mhealth Uhealth 2020;8:e17842.
  15. Product monograph for Saxenda. Mississauga, ON L5N 6M1. February 2021.

Cite this document as follows: Clinical Resource, Weight Loss: Helping Your Overweight and Obese Patients. Pharmacist’s Letter/Prescriber’s Letter. May 2021. [370520]

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