Have you tried all the diets–keto, paleo, vegan, intermittent fasting, dairy-free, sugar-free, wheat-free, gluten-free, all-good-things-in-life-free–you name it and have been unsuccessful at either losing or maintaining the weight?
Obesity, defined as a BMI greater than 30, is the number one cause of preventable disease and disability (even above smoking!). The risks of obesity include hypertension, high cholesterol, and type 2 diabetes mellitus. As an obese individual, losing weight just might save your life. It’s not that simple though, is it? Unfortunately, genetics, metabolism, age, insulin resistance, physical impairment, or other chronic conditions such as depression can be significant barriers to efforts at weight loss. This is where weight loss medications can be helpful.
Shedding pounds however is not as easy as injecting yourself or taking a pill. Research shows that medications in conjunction with lifestyle modifications have the best outcomes in weight loss management. The lifestyle changes include a healthy diet, increased physical activity, and behavioral interventions. Although a Mediterranean diet is the most successful for losing weight, this may not be for everyone. Many find it helpful to consult a nutritionist during the first year of weight loss management. The overall goal is to maintain a diet in which energy intake (how much you eat) is less than energy expenditure (how much you move). The best results in combating obesity involve both aerobic and resistance training. The behavior component, arguably the hardest part, refers to the focus on sustaining a routine of eating better foods and exercising. Those who struggle with cravings should try removing cues or environmental stimuli that trigger eating. For example, clearing all the unhealthy snacks out of your pantry is a start. Without them, what you’re craving will be out of sight and out of mind. If necessary, other options that may benefit are psychotherapy or self-help groups.
If incorporating lifestyle modifications is not leading to weight loss, then you may be a candidate for weight loss medications. Common pharmaceutical therapy includes GLP-1 receptor agonists (semaglutide, liraglutide), phentermine (either alone or in combination with topiramate), orlistat (a lipase inhibitor), and naltrexone/bupropion.
Semaglutide (Ozempic, Wegovy) and Liraglutide (Saxenda, Victoza) are long-acting GLP-1 receptor agonists administered via subcutaneous injections. It slows down digestion and sends a signal to the brain that you are already full in order to curb appetite. Semaglutide injections are once a week, while liraglutide is injected daily. Initially, you may feel nausea, diarrhea, and vomiting, but these side effects diminish with continued use. Other common complaints with these drugs are constipation and heartburn. Both semaglutide and liraglutide are contraindicated in pregnancy, patients with a risk of pancreatitis, and patients with a risk of medullary thyroid cancer.
Orlistat (Alli, Xenical) is a lipase inhibitor that works to stop the absorption of fat in the gastrointestinal tract. It not only facilitates weight loss but also works to reduce total cholesterol and “bad” cholesterol (LDL). The recommended dose for weight loss is 120 mg three times a day. Over-the-counter orlistat, also known as Alli, is dosed at 60 mg. Side effects include oily stools, cramps, and excessive gas, which can be minimized by avoiding high-fat diets and sticking to no more than 30% fat intake. Another downside of orlistat is that in its attempt to control how much fat is stored after eating, the essential fat-soluble vitamins such as vitamins A, D, E, and K are no longer absorbed from foods. It is highly suggested to take multivitamins daily with orlistat. Contraindications are pregnancy, chronic malabsorption, or a history of calcium oxalate stones.
Phentermine as a single agent is a widely prescribed weight loss medication belonging to the class of sympathomimetic drugs. It works by stimulating the release of certain hormones that help to suppress appetite. Side effects of phentermine are increased heart rate, increased blood pressure, dry mouth, constipation, nervousness, and the possibility of addiction. Because of this, it is contraindicated in patients with hypertension, hyperthyroidism, coronary heart disease, and in patients with a history of drug abuse.
Bupropion-naltrexone (Contrave) is an FDA-approved combination drug of bupropion, a dopamine-reuptake inhibitor, and naltrexone, an opioid-receptor antagonist. Together, this medication targets the areas of the brain that control hunger and energy use. Adverse effects include insomnia, vomiting, dizziness, and dry mouth. Because Contrave can raise blood pressure and heart rate, it may have cardiovascular effects, but its threat to the heart is yet to be fully studied. Bupropion is known to lower the seizure threshold, and therefore, should be avoided in those who are at risk of alcohol withdrawal or seizures. Other contraindications include pregnancy, uncontrolled hypertension, eating disorder, chronic opioid use, severe liver abnormalities, and use within 14 days of a monoamine oxidase inhibitor (i.e. isocarboxazid, phenelzine, selegiline, tranylcypromine).
If you struggle with obesity, you are not alone. Take charge of your health and make an appointment today for a weight management consult with our physician Dr. Makkani, at Katy-Fulshear Internal Medicine by calling (346) 500-5342 or using our online form to schedule an appointment.
Sources
- Perreault, L MD. Obesity in adults: Prevalence, screening, and evaluation. https://www.uptodate.com/contents/obesity-in-adults-prevalence-screening-and-evaluation?search=obesity%20management&topicRef=5371&source=see_link. Accessed Feb 10, 2023.
- Perreault, Leigh MD. Overweight and obesity in adults: Health consequences. https://www.uptodate.com/contents/overweight-and-obesity-in-adults-health-consequences?search=obesity%20management&topicRef=5371&source=see_link#H1026065041. Accessed Feb 10, 2023.
- Perreault, L MD, Apovian, C MD. Obesity in adults: Overview of management. https://www.uptodate.com/contents/obesity-in-adults-overview-of-management?search=obesity%20management&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#. Accessed Feb 12, 2023.
- Perreault, L MD. Obesity in adults: Drug therapy. https://www.uptodate.com/contents/obesity-in-adults-drug-therapy?sectionName=Orlistat&search=obesity%20management&topicRef=5371&anchor=H1723786361&source=see_link#H1695730010. Accessed Feb 12, 2023.
