How to Treat Severe Obesity as a Chronic Disease

Many patients with severe obesity (class 3, body mass index [BMI] 40 kg/m2) receive suboptimal care, a recent article in Mayo Clinic Proceedings suggests. With a primary focus on managing chronic conditions, clinicians may fail to treat their underlying cause.

Associated with heart disease, cancer and diabetes, severe obesity significantly reduces life expectancy. In the decade between 2000 and 2010, the prevalence of severe obesity increased by 70%. Although medical treatments for severe obesity exist—such as bariatric surgery and pharmacotherapy—even patients who receive regular medical care for chronic conditions are unable to lose weight.

A chronic disease in its own right

“Obesity is mainly responsible for the onset of the majority of chronic conditions that we treat daily in our clinics, but it is also a chronic disease in its own right,” says Bartolome Burguera, MD, PhD, Chairman of Cleveland Clinic’s Endocrinology & Metabolism Institute and lead author on the paper. “We need to work together with patients to change the old medical paradigm of treating the chronic conditions likely caused by excess weight, but not appropriately addressing obesity.”

In this most recent paper, Dr. Burguera and his colleagues suggest several steps that physicians can take to help their patients with severe obesity. These include:

• Addressing the underlying conditions. Many physiologic, psychiatric and iatrogenic factors can contribute to the development of severe obesity. Additionally, many common medications including antipsychotic agents, insulin, sulfonylureas, β-blockers and corticosteroids cause weight gain. By taking detailed personal, nutritional, weight and health histories, physicians may identify conditions that contribute to weight gain and/or maintenance, develop an optimal treatment plan and make appropriate referrals.
• Maximizing visit time. Creating multidisciplinary teams, including dietitians, advanced nurse specialists, exercise physiologists, psychologists and social workers allows the development of personalized treatment plans without overly taxing the healthcare provider.
• Rethinking outcomes. Setting small, achievable goals of 3-7% weight loss can improve glycemic control and decrease the risk of Type 2 diabetes while keeping patients motivated.
• Offering intensive behavioral therapy. Studies show that intensive behavioral therapy can significantly reduce cardiovascular risk factors, hospitalizations and healthcare costs while increasing quality of life.
• Combining counseling with pharmacotherapy. The U.S. Food and Drug Administration has approved a handful of effective antiobesity medications (i.e., orlistat, lorcaserin, naltrexone-bupropion sustained release, phentermine-topiramate extended release and liraglutide), which, when combined with counseling for obesity can nearly double the weight loss of either medication or counseling alone.
• Increasing knowledge about bariatric surgery: Patients, providers and payers often lack sufficient understanding of the efficacy and safety of current bariatric surgery for patients with severe obesity who have not achieved sufficient weight loss with intensive multidisciplinary, nonsurgical interventions.
• Recognizing biased beliefs about severe obesity. Physicians should pay close attention to their own potentially biased assumptions about the causes of and treatments for severe obesity, and strive to treat all patients with equal respect.

Listen with empathy

“I’ve worked at medical institutions on both sides of the Atlantic Ocean, and I’ve learned that patients with obesity are discriminated against, both explicitly and implicitly, regardless of where they live,” Dr. Burguera explains. “These patients are often treated with bias by their colleagues and, in many circumstances, by their physicians. I listen to patients with empathy and respect. I need to understand their concerns in order to work with them to develop therapeutic plans.”

An interdisciplinary approach

Under Dr. Burguera’s leadership, Cleveland Clinic has developed an interdisciplinary approach that includes working with the Employee Health Plan, and is centered on nutrition, physical activity, appetite control and optimization of sleeping habits, as well as psychological support focused on stress reduction and the treatment of anxiety and depression.

“In the next several years, we will continue to find innovative ways to treat patients with a focus on compassion and convenience. We want to create relaxed, supportive, personalized environments for the exchange of information,” Dr. Burguera says.