The “Obesity Management in Adults: A Review” article in JAMA 2023 by Arielle Elmaleh-Sachs and colleagues provides an extensive analysis of obesity, affecting 800 million people globally and 42% of U.S. adults. The review underscores the chronic nature of obesity, with a BMI of 30 or greater, and its associated risks, including comorbidities, premature mortality, and the impact of stigma and bias, particularly on women’s cancer screening rates. The financial burden in the U.S. is significant, estimated at $173 billion annually.

The authors performed an exhaustive literature review, including 2418 systematic reviews and meta-analyses since 2018, focusing on anti-obesity medications, obesity guidelines, and GLP-1 receptor agonist trials. They selected 126 high-quality articles, including randomized clinical trials (RCTs), meta-analyses, longitudinal studies, and guidelines, to inform their review.

The article highlights the increasing global prevalence of obesity, with a rise from 3.2% in men and 6.4% in women in 1975 to 10.8% and 14.9% respectively in 2014, and anticipated further increases. The prevalence varies across ethnic groups in the U.S., with the highest rates among non-Hispanic Black adults. The WHO’s Acceleration Plan aims to address obesity through policy measures targeting a reduction by 2030. Obesity’s complexity is attributed to genetic, environmental, and lifestyle factors, and it’s linked to various comorbidities like cardiovascular diseases and diabetes.

Comprehensive Strategies for Adult Obesity Management

Diagnosis and classification of obesity primarily use BMI, although it has limitations in directly measuring adiposity. The Edmonton Obesity Staging System provides an alternative risk classification. Waist circumference is another metric for assessing obesity-related cardiometabolic risk. Secondary causes of obesity, including hormonal and psychiatric disorders, are crucial in diagnosis and treatment planning.

The review emphasizes a patient-centered approach in obesity care, incorporating the 5As counseling strategy for shared decision-making and motivating weight loss. It highlights the importance of understanding disparities in obesity prevalence and considering social determinants of health. Setting personalized weight-loss goals and a comprehensive treatment plan involving behavioral interventions, nutrition, physical activity, pharmacotherapy, and bariatric procedures is recommended.

Pharmacotherapy advancements include several FDA-approved antiobesity medications, recommended alongside lifestyle changes for nonpregnant individuals with obesity-related complications. GLP-1 receptor agonists, such as semaglutide and liraglutide, are effective for weight loss and reducing cardiovascular risk. Tirzepatide shows significant weight loss, and other medications like phentermine-topiramate, naltrexone-bupropion, and orlistat offer various mechanisms and effects. Gelesis100, a nonsurgical device, and short-term sympathomimetic oral amines are additional options. Off-label metformin use shows modest weight loss benefits.

Comprehensive Strategies for Adult Obesity Management

Bariatric endoscopic procedures, FDA-approved for obesity treatment, include intragastric balloons and endoscopic sleeve gastroplasty. Intragastric balloons, suitable for patients with a BMI of 30 to 40, are removed after 6-8 months. Endoscopic sleeve gastroplasty reduces stomach volume and has shown significant weight loss compared to lifestyle modifications alone. Metabolic and bariatric surgery, such as laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass, are recommended for specific BMI ranges and have shown substantial weight loss results. Follow-up visits are critical for supporting lifestyle changes and managing complications.

The article concludes that maintaining weight loss is challenging and may require continuous clinical intervention. Longitudinal studies show successful weight maintenance often involves behavioral strategies like physical activity and a consistent eating pattern. The review underscores the necessity of lifelong monitoring and potential treatment escalation in obesity management.

Comment:  The article “Obesity Management in Adults” is a seminal piece, offering a holistic view of obesity’s complexity and its management. It adeptly bridges the gap between clinical guidelines and practical application, emphasizing a multidisciplinary approach that is vital for effective, patient-centered obesity care in today’s diverse population.

Prof. Dr. Prahlada N. B
2 December 2023

Reference / You can access the article at the following link:

Elmaleh-Sachs A, Schwartz JL, Bramante CT, Nicklas JM, Gudzune KA, Jay M. Obesity Management in Adults: A Review. JAMA. 2023;330(20):2000–2015. doi:10.1001/jama.2023.19897.

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