expert roundtables

Setting Realistic Weight-Loss Goals for Patients With Obesity-Related Cardiometabolic Risk Factors

by Caroline M. Apovian, MD, FACP, FTOS, DABOM, George A. Bray, MD, Xavier Pi-Sunyer, MD

Overview

Since obesity increases the risk for cardiovascular disease, hypertension, dyslipidemia, diabetes, stroke, gallbladder disease, respiratory problems, metabolic disorders, sleep apnea, and orthopedic disorders, chronic weight management is needed to reduce such risks. Current treatment approaches in chronic weight management also provide the additional health benefits associated with weight loss in patients with obesity. In patients with obesity and overweight, a weight loss of only 5% has been shown to significantly reduce cardiometabolic and other health risks, and additional weight loss can reduce mortality and further improve outcomes. A meta-analysis of 28 randomized trials (with 29,018 patients) of the US Food and Drug Administration–approved weight-loss medications orlistat, lorcaserin, naltrexone/bupropion, phentermine/topiramate, and liraglutide demonstrated that these medications were associated with weight loss and decreases in fasting blood glucose and waist circumference, with liraglutide being associated with a substantial decrease in waist circumference, fasting blood glucose, and hemoglobin A1c (HbA1c). Our featured experts in the field discuss setting realistic weight-loss goals in patients with obesity-related cardiometabolic risk factors to improve overall patient outcomes.


Q - In patients with obesity-related cardiometabolic risk factors, how do you go about setting realistic weight-loss goals, and over what time frame? 

F. Xavier Pi-Sunyer, MD

Professor of Medicine, Institute of Human Nutrition
Co-Director, Columbia Obesity/Nutrition Research Center
Columbia University
New York, NY

“I have helped write the National Institutes of Health guidelines that suggest that any weight loss of at least 5% from baseline has an impact on risk factors, primarily glucose risk factors for diabetes, lipid risk factors for cardiovascular disease, and inflammatory markers.”

F. Xavier Pi-Sunyer, MD

I have helped write the National Institutes of Health guidelines that suggest that any weight loss of at least 5% from baseline has an impact on risk factors, primarily glucose risk factors for diabetes, lipid risk factors for cardiovascular disease, and inflammatory markers. Predictably, patients tend to lose weight for approximately 6 months, and then they plateau and either maintain that weight or regain weight over the next 4 to 5 years. Therefore, the timeline for weight loss seems to be closely set at approximately 6 months, so that is what we try to emphasize when we work with patients with overweight or obesity. Generally, the weight-loss goal that is set at the beginning is 10%, but many patients do not achieve 10%. We do emphasize the goal of 10% weight loss as being significantly more effective in terms of risk factors. We have no long-term data on event rates, except for mortality. The available data are primarily regarding risk because most of the studies do not go on for long enough to document cardiometabolic events. There are a few studies, such as the Look AHEAD (Action for Health in Diabetes) and Diabetes Prevention Program (DPP) trials, that have long-term data, but, even in these studies, the event rates tend to take a very long time to occur.


Caroline Apovian, MD, FACP, FTOS, DABOM

Director, Nutrition and Weight Management
Section of Endocrinology, Diabetes, and Nutrition
Boston Medical Center
Professor of Medicine, Boston University School of Medicine
Boston, MA

“We are looking for a 5% to 10% weight loss, with our goal typically being 10%. We have numerous studies showing a decrease in the classic risk factors (eg, blood pressure, blood lipids, blood glucose, and HbA1c) with a 5% to 10% weight loss.”

Caroline M. Apovian, MD, FACP, FTOS, DABOM

Usually, patients will lose weight for up to 6 months, at which point they plateau. When they plateau, we are looking for maintenance up to 1 year. The Look AHEAD and the DPP trials showed us the trajectory of weight loss and what kind of weight loss can be achieved in most patients. We are looking for a 5% to 10% weight loss, with our goal typically being 10%. We have numerous studies showing a decrease in the classic risk factors (eg, blood pressure, blood lipids, blood glucose, HbA1c) with a 5% to 10% weight loss. We have adjunctive treatments on top of diet and exercise that we can use in some patients to push that envelope of 5% to 10%, but the studies show that we really never get beyond that 10%. At the outset, some patients can only lose 5%, but some patients, of course, can lose more than 10%. Some patients can lose 12% or 15%, but what we are looking for is a 5% to 10% weight loss. Currently, the average weight loss seen with adjunctive medications on top of behavioral therapy is between 5% and 10%, even though some patients can lose much more.

George A. Bray, MD

Boyd Professor Emeritus, LSU, 
Pennington Biomedical Research Center, 
Louisiana State University, 
New Orleans, LA

“For patients who do not achieve their weight-loss goals, we either need augmented therapy or additional therapy to help them lose weight to achieve the health benefits associated with a 5% to 10% weight loss.”

George A. Bray, MD

The time frame and weight-loss goals that my colleagues have outlined are very reasonable. However, unfortunately, some patients do not lose weight with standard treatment. This is very clear in the Look AHEAD study, where, even with intensive treatment, up to 25% of people lost less than 3%. For patients who do not achieve their weight-loss goals, we either need augmented therapy or additional therapy to help them lose weight to achieve the health benefits associated with a 5% to 10% weight loss. I think that we need a stopping rule. If a person does not lose 5% during the first 6 months, that means that he or she is probably not going to lose it in the next 6 months and therefore some other approach is clearly needed.

References

Bray GA, Frühbeck G, Ryan DH, Wilding JP. Management of obesity. Lancet. 2016;387(10031):1947-1956.

Bray GA. Why do we need drugs to treat the patient with obesity? Obesity (Silver Spring). 2013;21(5):893-899.

Ebbert JO, Elrashidi MY, Jensen MD. Managing overweight and obesity in adults to reduce cardiovascular disease risk. Curr Atheroscler Rep. 2014;16(10):445.

Jensen MD, Ryan DH, Donato KA, et al. Guidelines (2013) for managing overweight and obesity in adults. Obesity. 2014;22(S2):S1-S410.

Khera R, Pandey A, Chandar AK, et al. Effects of weight-loss medications on cardiometabolic risk profiles: a systematic review and network meta-analysis. Gastroenterology. 2018;154(5):1309-1319.e7.

Look AHEAD Research Group, Gregg EW, Jakicic JM, et al. Association of the magnitude of weight loss and changes in physical fitness with long-term cardiovascular disease outcomes in overweight or obese people with type 2 diabetes: a post-hoc analysis of the Look AHEAD randomised clinical trial. Lancet Diabetes Endocrinol. 2016;4(11):913-921.

Magkos F, Fraterrigo G, Yoshino J, et al. Effects of moderate and subsequent progressive weight loss on metabolic function and adipose tissue biology in humans with obesity. Cell Metab. 2016;23(4):591-601.

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