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Departments of Medicine and Pediatrics
Harvard Medical School
Obesity Medicine Physician Scientist
Neuroendocrine Unit and Pediatrics
Department of Medicine
Massachusetts General Hospital
Fatima Cody Stanford, MD, MPH, MPA, MBA, has disclosed that she has received consulting fees from Calibrate and Novo Nordisk.
Here’s my take on how an awareness of metabolic adaptation in patients with obesity can help them to maintain a healthy weight and to reduce the risk of cardiometabolic complications. Please download the slideset from the webinar, “Obesity Management Strategies That Can Reap the Benefits of Long-term Weight Loss,” and is available to share with colleagues.
Awareness of Metabolic Adaptation
When patients lose weight, the body desires to regain it via metabolic adaptation that decreases energy use, enhances metabolic efficiency, and prompts increased energy intake. With metabolic adaptation, a person recognizes that as they try a particular therapy, whether lifestyle, medication, surgery, or an endoscopic therapy, it initially feels relatively easy to do and maybe their weight responds. However, over time on therapy, continued weight loss becomes more and more challenging due to the alteration in hormone levels such as ghrelin, leptin, and glucagon-like peptide-1 (GLP-1). For example, increasing ghrelin levels stimulate a person to eat more, and falling GLP-1 levels cause a person to not feel as full.
Awareness of metabolic adaptation as we treat patients with the chronic disease of obesity is important as several downstream cardiometabolic complications will be affected, including heart disease, sleep apnea, diabetes, and fatty liver disease. We know that losing at least 5% of the patient’s weight leads to significant improvement, but as weight is regained, those benefits are lost. Therefore, we must work with patients and monitor them on a consistent basis to ensure that we recognize how their bodies are responding at any period in time. I continue to see my patients who become lean (and many of them do become lean), albeit less frequently, because bodies respond to the environment that they live in and to those hormonal changes that are happening in the body that tell us to eat more and store more as more time goes by. This includes incretin-based therapy such as GLP-1 receptor agonists: Patients initially feel they are never hungry, but the longer they take the medication, they start to think about eating certain foods as the body becomes acclimated to the GLP-1 receptor agonist. One modification that can be made is to add another medication. Perhaps new stressors, such as a death or a divorce—or even a pandemic—are present in the patient’s life. Therefore, I think that it is important to note that obesity is a chronic disease that requires chronic therapy that will need continuous fine-tuning.
Key Questions About Hunger and Satiety
I also think it is important for healthcare professionals to listen to the patient, and I ask my patients 2 key questions at every visit. First, I ask patients about the concept of hunger or how hungry they feel between meals. Responses may include: “I’m not really hungry,” “I eat because I’m supposed to eat but I’m not really hungry,” “I could eat,” “I’m noticing that it’s time to eat,” “I’m always thinking about food,” or “I’m always hungry.” The answer helps me to know where the patients are with their therapy.
Second, I ask patients about satiety or how long it takes them to feel full once they actually start eating. I ask, “Do you require a small portion, a medium portion, or a large portion to feel full?” Again, patients start noticing changes as time from the initiation of therapy increases. For example, after surgery, patients may say, “I have a very low level of hunger and I get full super quickly,” but 1 or 2 years post surgery, they say, “I can eat more now.” The feeling of satiety has huge implications for what the patient’s body is doing.
Pharmacotherapy for Weight Loss and After Bariatric Surgery
Physical activity is also a really great way to maintain weight, but if patients can’t do the things they want to do because of an impairment, such as an injury or mood disorder (eg, depression or bipolar disorder), modifications can be made to help patients be at the happiest, healthiest weight for them.
Patient-specific pharmacotherapy can be added after bariatric surgery to assist with weight loss. However, if the patient is continuously losing weight—there may be some people who continue to lose weight for 2 years post surgery even though that is not usual—pharmacotherapy is likely not needed. Another patient may start losing weight and then stop losing at 3 months after bariatric surgery. Since the average weight loss usually stops between 12 and 18 months, something needs to be done for that patient, and pharmacotherapy could be beneficial.
Pharmacotherapy must be tailored to the patient, as every single patient is different. Some patients never need medication, some need medication very early on, and some need medication later on. I think listening to the patients’ bodies and catching them at their nadir and when they plateau is really important, but if patients plateau well into a very lean category, medication is not required.
We can also use combination pharmacotherapy for patients after bariatric surgery, but I am thoughtful about starting one agent at a time and maximizing one agent before adding another agent. The reason why I think this is important is because if we view pharmacotherapy as a long-term strategy for weight regulation, and we start patients on 3 drugs at the same time, the patients will ask whether they need to take all 3 drugs forever and question whether they want to take all 3 drugs. We need to have patience, and I’m always astonished to see how variable people are in terms of their response. I may start a low dose of one medicine and the patient comes back with an additional 20-pound loss after surgery. It is important to be cautious and scientific in your approach by beginning with the lowest possible dose and titrating up as needed, one drug at a time. The patients’ lives after surgery are their full life, and we can treat them in a safe, cautious way based on the efficacy that they are experiencing. As mentioned earlier, it’s important to continue to monitor these patients. For surgical patients, if their labs look great and there is no evidence of any deficiencies, the maximum time between visits should be 1 year, but most people are being seen more frequently, especially if they are on medications. Patients whose medications may need tweaking should be seen every 3-6 months. I see many of my patients much more frequently than they would see their primary care practitioners because their treatment requires a lot of that fine-tuning.
How often do you see your patients with obesity and who are on pharmacotherapy in the clinic? Answer the polling question and join the conversation in the comments section.