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Clinical question
What approaches to the treatment of obesity in adults are safe and
effective?
Bottom line
On the basis of flimsy evidence of benefit, The American College of
Physicians recommends drug therapy for the treatment of obesity. They also
recommend gastric bypass surgery, performed by an experienced surgeon, for
patients with marked obesity and other risk factors for premature death.
Reference
Snow V, Barry P, Fitterman N, Qaseem A, Weiss K, for the Clinical Efficacy
Assessment Subcommittee of the American College of Physicians. Pharmacologic
and surgical management of obesity in primary care: A clinical practice
guideline from the American College of Physicians. Ann Intern Med 2005;
142:525-31. Li Z, Maglione M, Tu W, et al. Meta-analysis: Pharmacologic
treatment of obesity. Ann Intern Med 2005; 142:532-46.
Study design:
Practice guideline
Setting:
Various (guideline)
Synopsis
This evidence-linked report from the American College of Physicians gives
weight-loss guidance for patients with a body mass index (BMI) of at least
30 kg/m2. The authors do a nice job, along with the authors of the companion
meta-analysis, of summarizing the evidence. Their recommendation for initial
treatment -- in keeping with other guidelines -- is general diet and
exercise counseling, although they don't offer any support that it actually
works to cause weight loss or improve patient outcomes. They recommend
pharmacologic therapy when these measures don't work, with the seemingly
contradicting cautions that the weight loss will be minimal (<5 kg at 1
year), the weight loss is likely temporary, and there is no evidence that
this modest weight loss actually benefits the patients. Recommended drugs
include the newer sibutramine (Meridia) and orlistat (Xenical), the older
drugs diethylpropion and phentermine, and the antidepressants fluoxetine
(Prozac) and bupropion (Wellbutrin, Zyban). Bariatric surgery (gastric
bypass) at high-volume centers should be considered for patients with a BMI
of at least 40 kg/m2 who have obesity-related conditions, such as
hypertension, impaired glucose tolerance or diabetes, hyperlipidemia, or
obstructive sleep apnea. The authors also point out, however, that the
reported mortality rate associated with this surgery ranges from 3 to 19 per
1000 surgeries and can be quite high (5%) for surgeons who have performed
fewer than 20 surgeries. |