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Tuesday, April 12, 2005

Physician's Guide to Pharmalogical (Drug) and Surgery for Obesity Patients

Katherine Prouty at Low Carb Freedom has presented this update from the Annals of Internal Medicine, take a look:

The Annals of Internal Medicine has come out with new guidelines, or, rather, codified guidelines, for the treatment of obesity. Diet and Exercise is the number one method, but it isn't covered extensively, at least in this paper. There are five recommendations:

Recommendation 1: Clinicians should counsel all obese patients (defined as those with a BMI 30 kg/m 2 ) on lifestyle and behavioral modifications such as appropriate diet and exercise, and the patient's goals for weight loss should be individually determined (these goals may encompass not only weight loss but also other parameters, such as decreasing blood pressure or fasting blood glucose levels).

Recommendation 2: Pharmacologic therapy can be offered to obese patients who have failed to achieve their weight loss goals through diet and exercise alone. However, there needs to be a doctor–patient discussion of the drugs' side effects, the lack of long-term safety data, and the temporary nature of the weight loss achieved with medications before initiating therapy.

Recommendation 3: For obese patients who choose to use adjunctive drug therapy, options include sibutramine, orlistat, phentermine, diethylpropion, fluoxetine, and bupropion. The choice of agent will depend on the side effects profile of each drug and the patient's tolerance of those side effects.

Recommendation 4: Surgery should be considered as a treatment option for patients with a BMI of 40 kg/m 2 or greater who instituted but failed an adequate exercise and diet program (with or without adjunctive drug therapy) and who present with obesity-related comorbid conditions, such as hypertension, impaired glucose tolerance, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea. A doctor–patient discussion of surgical options should include the long-term side effects, such as possible need for reoperation, gall bladder disease, and malabsorption.

Recommendation 5: Patients should be referred to high-volume centers with surgeons experienced in bariatric surgery.

Basically, there is a loop that always leads back to diet and exercise as you go down the choices. If, step 1, diet and exercise don't work, then, in step 2, offer weight loss drug therapy, but tell everyone the side effects and temporary nature of the weight loss. Step 3 talks about specific weight loss drugs.

If weight loss drugs don't work, then move to step 4, and offer them weight loss surgery, with all the precautions and potential problems. If weight loss surgery is the solution, then, in step 5, help them choose a high volume surgery center.

Seems like common sense. Further in the recommendation is this paragraph:

Lifestyle modification through diet and exercise should always be recommended for all obese patients. In addition, patients need to be continuously educated regarding diet and exercise, and it should be clear that after a surgical procedure patients cannot resume their previous eating habits. There is no evidence at present to answer the question of whether one procedure is better than another. In addition, weight loss through surgery has not been shown to reduce cardiovascular morbidity or mortality. (emphasis mine)

Basically, after weight loss surgery, you have to go on a low carb diet. So, for those who are thinking about weight loss surgery, why not try it out on a voluntary basis first before going through the surgery.

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