A Protocol to Deliver Intensive Behavioral Therapy (IBT) for Obesity in Primary Care Settings: The MODEL-IBT Program

BRIDGE to liver health: implementation of a group telehealth psychoeducational program through shared medical appointments for MASLD management

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) represents a significantly costly and increasingly prevalent disease, with treatment focused on lifestyle intervention. Integrating education and behavioral health into clinical care offers opportunities to engage and empower patients to prevent progression of liver disease. We describe the design and implementation of Behavioral Resources and Intervention through Digital Group Education (BRIDGE), a 6-session group telehealth program led by advanced practice providers (APPs) in 90-min shared medical appointments (SMAs) with small groups of MASLD patients in an academic outpatient hepatology clinic. The program contains multi-component group interventions, with didactic education and behavioral coaching, while leveraging peer-based learning and support.

METHODS

A mixed-methods exploratory pilot study was conducted. Feasibility and acceptability of the clinical intervention were assessed by tracking recruitment, attendance, and retention of BRIDGE participants, patient interviews, and debriefing of clinician and staff views of the clinical program. Implementation metrics included program development time, workflow and scheduling logistics, and billing compliance for sustainability. Finally, patient parameters including changes in liver enzymes, FIB-4, weight, and BMI from pre- to post-BRIDGE were retrospectively analyzed.

RESULTS

We included 57 participants (median age 57, interquartile range (IQR) 50 - 65 years), 38 (67%) female, 38 (67%) white, and 40% had public insurance. Thirty-three (58%) participants completed all six sessions, while 43 (75%) attended at least five sessions. Patients who completed all sessions were older (median age 61 vs 53.5; p = 0.01). Gender, race/ethnicity, and insurance type were not significantly associated with missed sessions, and patients had similar rates of completion regardless of weight, BMI, or stage of liver disease. Barriers to completion included personal illness, family reasons, work commitments, or insurance issues. Prior to BRIDGE, median BMI was 31.9 (SD 29 - 36), with a median weight loss of 2 pounds (IQR -2 - 6) after BRIDGE.

CONCLUSION

The BRIDGE telehealth SMA program was feasible, well-attended, and positively reviewed. This pilot study informs future iterations of program development and evaluation of outcome measures.

The Role of Lifestyle Modification with Second-Generation Anti-obesity Medications: Comparisons, Questions, and Clinical Opportunities

PURPOSE OF REVIEW

This review examines lifestyle modification for obesity management with the goal of identifying treatment components that could support the use of a new generation of anti-obesity medications (AOMs).

RECENT FINDINGS

Semaglutide reliably reduces baseline body weight by approximately 15% at 68 weeks, in contrast to 5-10% for lifestyle modification. Tirzepatide induces mean losses as great as 20.9%. Both medications reduce energy intake by markedly enhancing satiation and decreasing hunger, and they appear to lessen the need for traditional cognitive and behavioral strategies (e.g., monitoring food intake) to achieve calorie restriction. Little, however, is known about whether patients who lose weight with these AOMs adopt healthy diet and activity patterns needed to optimize body composition, cardiometabolic health, and quality of life. When used with the new AOMs, the focus of lifestyle modification is likely to change from inducing weight loss (through calorie restriction) to facilitating patients' adoption of dietary and activity patterns that will promote optimal changes in body composition and overall health.

Five-year Weight Loss Maintenance With Obesity Pharmacotherapy

CONTEXT

Long-term treatment of obesity with lifestyle changes alone is unsustainable for most individuals because of several factors including adherence and metabolic adaptation. Medical management of obesity has proven efficacy for up to 3 years in randomized controlled trials. However, there is a dearth of information regarding real-world outcomes beyond 3 years.

OBJECTIVE

This work aimed to assess long-term weight loss outcomes over a 2.5- to 5.5-year period with US Food and Drug Administration (FDA)-approved and off-label antiobesity medications (AOMs).

METHODS

A cohort of 428 patients with overweight or obesity were treated with AOMs at an academic weight management center with an initial visit between April 1, 2014, and April 1, 2016. Intervention included FDA-approved and off-label AOMs. The primary outcome was percentage weight loss from initial to final visit. Key secondary outcomes included weight reduction targets as well as demographic and clinical predictors of long-term weight loss.

RESULTS

The average weight loss was 10.4% at a mean follow-up duration of 4.4 years. The proportions of patients who met the weight reduction targets of 5% or greater, 10% or greater, 15% or greater, and 20% or greater were 70.8%, 48.1%, 29.9%, and 17.1%, respectively. On average, 51% of maximum weight loss was regained, while 40.2% of patients maintained their weight loss. In a multivariable regression analysis, a higher number of clinic visits was associated with more weight loss. Metformin, topiramate, and bupropion were associated with increased odds of maintaining 10% or greater weight loss.

CONCLUSION

Clinically significant long-term weight loss of 10% or more beyond 4 years is achievable in clinical practice settings with obesity pharmacotherapy.

Semaglutide for the treatment of obesity

Semaglutide is a glucagon-like peptide-1 receptor agonist that was recently approved by the US Food and Drug Administration for chronic weight management. This paper reviews data on the mechanism of action, weight-loss and cardiometabolic efficacy, and safety of semaglutide 2.4 mg/week for obesity. Semaglutide has demonstrated the largest weight loss of any obesity medication to date with reductions of approximately 15% of initial weight at 68 weeks, accompanied by improvements in cardiovascular risks factors and physical functioning. The approval of this medication provides patients with greater options for weight management.

Passive recruitment reach of a lifestyle management program to address obesity in the deep south during the COVID-19 pandemic

Obesity is a significant public health concern, especially in the Deep South and in Mississippi where prevalence is among the worst in the nation paired, with other poor health outcomes and socioeconomic conditions. Lifestyle management programs that address modifiable risk factors, such as nutrition and physical activity, can be effective mitigation strategies to halt weight accumulation patterns and ameliorate metabolic risk factors for some populations. However, there is limited evidence regarding the implementation of effective practice models to address obesity risk in underserved and underrepresented populations, such as African Americans, and people in the stage of earlier adulthood. Furthermore, there is growing evidence supporting the impact of the COVID-19 pandemic on lifestyle management programs that should be considered in these populations. The purpose of this manuscript was to describe the development and telehealth implementation of a weight management program during the COVID-19 pandemic and provide a preliminary examination of recruitment strategies and baseline characteristics for enrolled participants. Passive recruitment (social media, web, email, and other media advertisements) resulted in 157 screening initiations, and 79 of those participants met the study inclusion criteria. Further, of the 79 eligible participants, 38 completed all study enrollment requirements and presented with metabolic abnormalities. The study findings add to the emerging body of evidence for how the pandemic may have impacted lifestyle management programs and is representative of an understudied and underrepresented population.

Intensive behavioral Therapy for weight loss in patients with, or At-Risk of, type 2 Diabetes: Results from the PaTH to health diabetes study

Intensive behavioral therapy (IBT) is an important component of obesity treatment and can reduce the risk of type 2 diabetes (T2DM). Objective was to compare the effectiveness of IBT to usual care in achieving weight loss in two study cohorts within PaTH Network: T2DM and At-Risk of T2DM. The TD2M cohort was defined as age 18 years and older with an indication of T2DM in the EHR based on a validated algorithm and at least 2 outpatient primary care visits. The At-Risk of T2DM cohort was defined by a BMI ≥ 25 kg/m². The primary outcome was weight change within 1-year of index date. Mixed-effects models assessed the effectiveness of IBT by comparing the changes between study groups. Between 2009 and 2020, a total of 567,908 patients were identified in the T2DM cohort and2,054,256 patients in the At-Risk of T2DM cohort. Both IBT patients and matched non-IBT patients in the T2DM cohort had decreased mean weight (primary outcome) (-1.56 lbs, 95 %CI: -1.88, -1.24 vs -1.70 lbs, 95 %CI: -1.95, -1.44) in 1-year after index date. In the At-Risk of T2DM cohort, both IBT and non-IBT patients experienced weight gain and resultant increased BMI. Patients with more than one IBT visit gained less weight than those with only one visit (1.22 lbs, 95 %CI: 0.82, 1.62 vs 6.72 lbs, 95 %CI: 6.48, 6.97; p < 0.001). IBT was unlikely to result in clinically significant weight loss. Barriers to utilizing IBT require further research to ensure broader adoption of obesity management in primary care.

Effectiveness of a 12-Month Online Weight Reduction Program in Cohorts with Different Baseline BMI-A Prospective Cohort Study

The purpose of this article was to answer the question of whether people who want to reduce their body weight can achieve different results depending on their baseline BMI and whether the rate of weight loss is constant over the months of intervention. The study included 400 individuals aged 19 to 55 years with a mean BMI of 31.83 ± 4.77 (min 25.1 max 51.8). Men comprised 190 subjects and women 210 subjects. The participants were divided into three groups with the following BMI: overweight, class 1 obesity, and obesity class > 1 (class 2 and 3 combined). BMI groups were randomized by gender, the number of trainings per week, training time, intervention length, and intervention type. The online intervention consisted of a 15% energy deficit diet and training. Over the 12-month dietary intervention, overweight subjects reduced average body weight by 16.6%. The group with class 1 obesity reduced body weight by 15.7%. The group with obesity class > 1 reduced mean body weight by 15.4%. The relative weight reduction in the overweight group was significantly greater than in the other obesity groups (p = 0.007). In all groups, the rate of weight loss from month-to-month was statistically significant (p = 0.0001), ranging between 0.6 and 2.6% per month. The results indicate that overweight individuals are likely to experience a percent greater weight loss as a result of a comprehensive lifestyle intervention. Regardless of baseline BMI, the observed weight loss was consistent from month-to-month throughout the 12-month period, which may indicate that the diet, as well as, the training plan were properly tailored to the subjects’ needs and that they were highly motivated to participate in the program throughout its course. Properly conducted lifestyle intervention enables significant weight loss regardless of baseline BMI values.

Incidence of Obesity at 1 and 3 Years Among Community Dwelling Adults: A Population-Based Study

OBJECTIVE

This study determined the incidence rates for obesity among adult patients ages 20 and older empaneled in primary care practice in Midwest United States to potentially identify an optimum timeframe for initiating intervention.

BACKGROUND

Primary care practice patients are likely to reflect underlying community trends in overweight and obesity; however, data on overweight and obesity in primary care patients is limited. While childhood incidence rates of obesity have been well reported, there is still a paucity of data on the incidence of obesity among adult population; literature has mainly focused on its prevalence.

METHODS

Medical record review of identified cohort with BMI data was conducted. Population was stratified by age and sex and overweight category was subdivided into tertiles.

RESULTS

Majority of 40 390 individuals who comprised the final population and had follow-up data, consisted of adults ages 40 to 69 years (47.5%), female (59.8%) of non-Hispanic ethnicity (95.9%) with 21 379 (52.8%) falling in weight category of overweight. Incidence of obesity was 7% at 1 year and 16% at 3 years follow-up. Highest percentages of individuals who became obese at 1 and 3 years were in age category of 40 to 69 years among men and 20 to 39 years among women. In Cox regression analysis, there was statistically significant association to developing obesity among all tertile groups in the overweight category. Age and particularly gender appeared to be modifying factors to likelihood of developing obesity.

CONCLUSION

Study results suggest that while obesity incidence is higher among certain age groups in both genders, middle-aged women, and men in all tertiles of overweight category are at highest risk and may be the optimum population to target for weight loss interventions. Findings support the initiation of population-based interventions before onset of obesity.

The Joys and Challenges of Delivering Obesity Care: a Qualitative Study of US Primary Care Practices

BACKGROUND

Obesity is of epidemic proportion in the USA but most people with obesity do not receive treatment.

OBJECTIVE

To explore the experience of providing obesity management among primary care clinicians and their team members involved with weight loss in primary care practices. The study's focus was on examining the use of the Medicare payment code for intensive behavioral therapy for obesity (IBT), but other obesity management services and payment mechanisms were also studied.

DESIGN/PARTICIPANTS

We conducted 85 interviews of clinicians (physician, advanced practice clinicians, registered dietitian, or other) practicing in primary care practices. Interviews gathered information about treatment approach to obesity, barriers, and facilitators to providing obesity care including the handling of billing and reimbursement (especially use of the IBT code), personal beliefs about the appropriateness of primary care providing weight loss services, and recommendations for improving weight management in primary care practice. The analysis was conducted using a grounded theory hermeneutic editing approach and the constant comparative method.

KEY RESULTS

Seventy-five interviews were included in this analysis. We identified three primary themes: (1) clinicians and staff involved in obesity management in primary care believe that addressing obesity is an essential part of primary care services, (2) because providing obesity care can be challenging, many practices opt out of treatment, and (3) despite the challenges, many clinicians and others find treating obesity feasible, satisfying, and worthwhile.

CONCLUSIONS

Treating obesity in primary care settings poses several challenges but can also be very satisfying and rewarding. To improve the ability of clinicians and practice members to treat obesity, important changes in payment, education, and work processes are necessary.

Success and failures of telehealth during COVID-19 should inform digital applications to combat obesity

Background

In response to the COVID-19 pandemic, telehealth digital applications (apps) permitted the delivery of health care to millions of individuals, including those with poor access to health services.

Aim

To review a body of evidence demonstrating that telehealth and mobile health (mHealth) apps can promote clinically meaningful weight loss, and thus hold potential to increase access to treatment and weight loss care for individuals suffering from obesity.

Results

Data from COVID-19 pandemic revealed that access to telehealth and mHealth remains a challenge for underserved communities that are disproportionately affected by obesity.

Conclusions

The development of telehealth and mHealth for obesity treatment must be informed by the success and failures of telehealth during the COVID-19 pandemic. Failure to do so, risks alienating the very populations that stand most to benefit from telehealth and mHealth apps for obesity treatment.

Measuring What Matters: Beyond Quality Performance Measures in Caring for Adults with Obesity

Obesity is a chronic disease that poses serious health and societal burdens. Although guidelines exist for obesity management in primary care, evaluating the success of obesity treatment programs is hampered by lack of established, robust quality measures. This study aimed to develop, and test for feasibility, measures for operational tracking, quality performance, and patient-centered care in the context of a national collaborative to develop a model for obesity management in the US primary care setting. The authors developed and evaluated 7 measures used to track the care of patients with overweight or obesity (n = 226,727 at baseline) receiving care within 10 health care organizations (HCOs). Measure categories included: (1) operational tracking (obesity/overweight prevalence and prevalence of obesity-related complications); (2) quality performance (obesity diagnosis, change in weight over time, anti-obesity medication prescriptions, and assessment of obesity-related complications); and (3) patient-centered care (patient-reported outcomes). Measures were tested for feasibility, variability across HCOs, ability to detect differences over time, and value to the HCOs. All measures were feasible to collect, provided value to the participating HCOs, and demonstrated variation and ability to detect differences over time (eg, rates of documented diagnosis of obesity classes 1, 2, and 3 increased from 29%, 46%, and 66%, respectively, at baseline to 35%, 53%, and 71% at study end). This study confirmed the feasibility and perceived value of 7 operational, performance, and patient-centered measures collected in primary care practices in 10 HCOs over an 18-month period.

Weight Can't Wait: A Guide to Discussing Obesity and Organizing Treatment in the Primary Care Setting

OBJECTIVE

The objective of this study was to develop a simple and practical guide for discussing and managing obesity in primary care settings.

METHODS

This study convened representatives from 12 primary care and obesity specialty organizations for a series of roundtable meetings to discuss the key components of obesity treatment in primary care. Attendees identified the need for a guide for primary care providers that outlined the key steps for discussing obesity with patients and managing their care while recognizing the significant time constraints on such provider/patient encounters.

RESULTS

Prevailing themes from the roundtable sessions suggested that the key components of addressing obesity in primary care settings are obtaining patient permission, addressing weight bias, providing a diagnosis, and emphasizing shared decision-making. A modified "6A" framework with the steps "Ask," "Assess," "Advise," "Agree," "Assist," and "Arrange" was deemed appropriate to organize the process of weight management in primary care. An algorithm was developed to provide a script for the patient/provider encounter.

CONCLUSIONS

The expert panel developed a short, accessible, practical, and informative guide for obesity management by primary care clinicians. Efforts are under way to disseminate the guide to primary care providers through the 11 participating organizations that have endorsed it.

Using multi-disciplinary teams to treat obese patients helps improve clinical efficacy: the general practitioner's perspective

OBJECTIVE

This paper aims to explore the influences of multi-disciplinary teams (MDT) from the general practitioner's (GP's) perspective on the clinical efficacy of treating obese patients.

METHODS

Admitted to our hospital from January 2018 to October 2019, 127 obese patients were divided into two groups based on the different models of diagnosis and treatment each underwent. The routine diagnostic and treatment model was administered to the patients in the control group (60 cases), and the MDT model was administered to the patients in the research group (67 cases). The weight loss success rates in both groups were observed. Before and after the treatment, the blood glucose, blood lipid, tumor necrosis factor-α (TNF-α), adiponectin (APN), leptin (LP), and recombinant human fibroblast growth factor 21 (FGF-21) levels were measured. The SAS and SDS scores were evaluated.

RESULTS

After the treatment, the weight loss success rate in the research group was significantly higher than it was in the control group, and the FPG and the 2hPBG levels were significantly lower in the research group. Compared with the control group, the TC, TG, and LDL-C levels were remarkably lower in the study group, and the HDL-C levels were remarkably higher in the research group. The TNF-α, LP, and FGF-21 levels were significantly lower in the research group, and the APN levels were significantly higher. The research group had significantly lower SAS and SDS scores and higher GSES scores.

CONCLUSION

MDTs from the GP's perspective are conducive to increasing the weight loss success rate and improving the blood glucose, blood lipid and adipokine levels in obese patients.

We Should Do More to Offer Evidence-Based Treatment for an Important Modifiable Risk Factor for COVID-19: Obesity

Observational studies, from multiple countries, repeatedly demonstrate an association between obesity and severe COVID-19, which is defined as need for hospitalization, intensive care unit admission, invasive mechanical ventilation (IMV) or death. Meta-analysis of studies from China, USA, and France show odds ratio (OR) of 2.31 (95% CI 1.3-4.1) for obesity and severe COVID-19. Other studies show OR of 12.1 (95% CI 3.25-45.1) for mortality and OR of 7.36 (95% CI 1.63-33.14) for need for IMV for patients with body mass index (BMI) ≥ 35 kg/m². Obesity is the only modifiable risk factor that is not routinely treated but treatment can lead to improvement in visceral adiposity, insulin sensitivity, and mortality risk. Increasing the awareness of the association between obesity and COVID-19 risk in the general population and medical community may serve as the impetus to make obesity identification and management a higher priority.

Effect of Behavioral Therapy With In-Clinic or Telephone Group Visits vs In-Clinic Individual Visits on Weight Loss Among Patients With Obesity in Rural Clinical Practice: A Randomized Clinical Trial

IMPORTANCE

Rural populations have a higher prevalence of obesity and poor access to weight loss programs. Effective models for treating obesity in rural clinical practice are needed.

OBJECTIVE

To compare the Medicare Intensive Behavioral Therapy for Obesity fee-for-service model with 2 alternatives: in-clinic group visits based on a patient-centered medical home model and telephone-based group visits based on a disease management model.

DESIGN, SETTING, AND PARTICIPANTS

Cluster randomized trial conducted in 36 primary care practices in the rural Midwestern US. Inclusion criteria included age 20 to 75 years and body mass index of 30 to 45. Participants were enrolled from February 2016 to October 2017. Final follow-up occurred in December 2019.

INTERVENTIONS

All participants received a lifestyle intervention focused on diet, physical activity, and behavior change strategies. In the fee-for-service intervention (n = 473), practice-employed clinicians provided 15-minute in-clinic individual visits at a frequency similar to that reimbursed by Medicare (weekly for 1 month, biweekly for 5 months, and monthly thereafter). In the in-clinic group intervention (n = 468), practice-employed clinicians delivered group visits that were weekly for 3 months, biweekly for 3 months, and monthly thereafter. In the telephone group intervention (n = 466), patients received the same intervention as the in-clinic group intervention, but sessions were delivered remotely via conference calls by centralized staff.

MAIN OUTCOMES AND MEASURES

The primary outcome was weight change at 24 months. A minimum clinically important difference was defined as 2.75 kg.

RESULTS

Among 1407 participants (mean age, 54.7 [SD, 11.8] years; baseline body mass index, 36.7 [SD, 4.0]; 1081 [77%] women), 1220 (87%) completed the trial. Mean weight loss at 24 months was -4.4 kg (95% CI, -5.5 to -3.4 kg) in the in-clinic group intervention, -3.9 kg (95% CI, -5.0 to -2.9 kg) in the telephone group intervention, and -2.6 kg (95% CI, -3.6 to -1.5 kg) in the in-clinic individual intervention. Compared with the in-clinic individual intervention, the mean difference in weight change was -1.9 kg (97.5% CI, -3.5 to -0.2 kg; P = .01) for the in-clinic group intervention and -1.4 kg (97.5% CI, -3.0 to 0.3 kg; P = .06) for the telephone group intervention.

CONCLUSIONS AND RELEVANCE

Among patients with obesity in rural primary care clinics, in-clinic group visits but not telephone-based group visits, compared with in-clinic individual visits, resulted in statistically significantly greater weight loss at 24 months. However, the differences were small in magnitude and of uncertain clinical importance.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02456636.

The risk of cardiovascular complications with current obesity drugs

INTRODUCTION

Obesity is associated with an increased risk of cardiovascular morbidity and mortality. Four medications are approved by the US Food and Drug Administration (FDA) for chronic weight management when used as an adjunct to a reduced-calorie diet and increased physical activity in adults. These medications result in clinically significant weight losses, as well as improvements in some cardiometabolic risk factors.

AREAS COVERED

We briefly review the history of anti-obesity medications (AOMs) as related to cardiovascular safety, and summarize weight loss efficacy and cardiovascular data from clinical trials of orlistat, phentermine/topiramate, naltrexone/bupropion, and liraglutide.

EXPERT OPINION

Current AOMs approved for chronic weight management have generally favorable effects on some cardiometabolic parameters. However, the long-term safety of orlistat, phentermine/topiramate, and naltrexone/bupropion on cardiovascular morbidity and mortality have not been established. The cardiovascular safety of liraglutide, at a dose of 1.8 mg/d, was demonstrated in a large randomized outcomes trial in participants with type 2 diabetes.

The association of obesity with health insurance coverage and demographic characteristics: a statewide cross-sectional study

We evaluated the statewide burden of obesity and its complications among government and state funded programs (Medicare and Medicaid) and commercial insurance.We calculated the prevalence of obesity and the prevalence of relevant comorbidities among different demographic groups and based on health insurance, among adults (18-65 years old) who visited a statewide health network in the state of Rhode Island, in 2017.The overall prevalence of obesity among 74,089 individuals was 38.88% [Asians 16.77%, Whites 37.49%, Hispanics 44.23%, and Blacks 48.44%]. Medicare or Medicaid beneficiaries were 26% and 27%, respectively, more likely to have obesity than those who had commercial insurance (Odds Ratio:1.26, 95% confidence interval [CI]:1.20-1.32; Odds Ratio:1.27, 95%CI:1.22-1.32). Moreover, Medicaid and Medicare beneficiaries with obesity had a higher prevalence of diabetes compared with privately insured with obesity (10.58% and 10.44% vs 4.45%). Medicare beneficiaries with obesity had a statistically higher prevalence of ischemic heart disease (4.34%, 95%CI: 3.77-4.91) than privately insured (3.21%, 95%CI: 2.94-3.47).Based on statewide data among 18 to 65 years old adults, Medicare and Medicaid provide health coverage to 40% of individuals with obesity and 46% of those with the obesity-related comorbidities and complications. State and federal health care programs need to support and expand obesity-related services and coverage.

Semaglutide 2.4 mg for the Treatment of Obesity: Key Elements of the STEP Trials 1 to 5

OBJECTIVE

The obesity epidemic is a public health concern, warranting further research into pharmacological treatments for weight management (WM) as an adjunct to lifestyle interventions. The Semaglutide Treatment Effect in People with obesity (STEP) program aims to investigate the effect of semaglutide versus placebo on weight loss, safety, and tolerability in adults with obesity or overweight.

METHODS

Across five phase 3 trials (NCT03548935, WM; NCT03552757, WM in type 2 diabetes; NCT03611582, WM with intensive behavioral therapy; NCT03548987, sustained WM; and NCT03693430, long-term WM), ~5,000 participants are being randomly assigned to receive semaglutide 2.4 mg once weekly subcutaneously versus placebo. Results will be available in 2020/2021. For all trials, the primary end point is change from baseline to end of treatment in body weight.

RESULTS

Participants have a mean age of 46.2 to 55.3 years, are mostly female (mean: 74.1%-81.0%), and have a mean BMI of 35.7 to 38.5 kg/m2 and a mean waist circumference of 113.0 to 115.7 cm.

CONCLUSIONS

The STEP program evaluates the efficacy and safety of semaglutide 2.4 mg subcutaneously once weekly in a broad population. The trials will provide insights on WM in people with obesity with and without type 2 diabetes and on long-term follow-up.

The obesity epidemic in the face of homeostatic body weight regulation: What went wrong and how can it be fixed?

Ever since the pioneering discoveries in the mid nineteen hundreds, the hypothalamus was recognized as a crucial component of the neural system controlling appetite and energy balance. The new wave of neuron-specific research tools has confirmed this key role of the hypothalamus and has delineated many other brain areas to be part of an expanded neural system sub serving these crucial functions. However, despite significant progress in defining this complex neural circuitry, many questions remain. One of the key questions is why the sophisticated body weight regulatory system is unable to prevent the rampant obesity epidemic we are experiencing. Why are pathologically obese body weight levels defended, and what can we do about it? Here we try to find answers to these questions by 1) reminding the reader that the neural controls of ingestive behavior have evolved in a demanding, restrictive environment and encompass much of the brain's major functions, far beyond the hypothalamus and brainstem, 2) hypothesizing that the current obesogenic environment impinges mainly on a critical pathway linking hypothalamic areas with the motivational and reward systems to produce uncompensated hyperphagia, and 3) proposing adequate strategies for prevention and treatment.

Measures of adherence as predictors of early and total weight loss with intensive behavioral therapy for obesity combined with liraglutide 3.0 mg

Individual weight loss outcomes with intensive behavioral therapy (IBT) for obesity are variable. The present study assessed whether visit attendance, dietary self-monitoring, medication, and meal-replacement adherence were associated with 52-week weight loss with IBT and tested whether these relationships were independent of associations with early weight loss. This was a secondary analysis of a randomized trial in which 150 participants (76.1% female, 55.8% white, BMI = 38.8 ± 4.8 kg/m²) received either IBT alone, IBT with liraglutide 3.0 mg/d, or IBT-liraglutide combined with a 12-week meal replacement diet (Multi-component). In the full sample, visit attendance accounted for 14.8% of the variance in 52-week weight loss and dietary self-monitoring added 14.9%. Only self-monitoring was independently associated with weight loss. In the 100 liraglutide-treated participants, medication adherence accounted for an additional 9.9% of the variance in 52-week weight loss, and both self-monitoring and medication adherence were independent correlates. For the 50 Multi-component participants, meal replacement adherence did not predict weight loss. Early weight loss was associated with higher early and subsequent session attendance and dietary self-monitoring. However, self-monitoring and medication adherence remained important correlates of total weight loss when controlling for this variable. Strategies that help improve self-monitoring consistency and medication usage could improve weight loss with IBT.

Liraglutide 3.0 mg and Intensive Behavioral Therapy (IBT) for Obesity in Primary Care: The SCALE IBT Randomized Controlled Trial

OBJECTIVE

Previous studies have shown additive weight loss when intensive behavioral therapy (IBT) was combined with weight-loss medication. The present multisite study provides the first evaluation, in primary care, of the effect of the Centers for Medicare and Medicaid Services-based IBT benefit, delivered alone (with placebo) or in combination with liraglutide 3.0 mg.

METHODS

The Satiety and Clinical Adiposity-Liraglutide Evidence in individuals with and without diabetes (SCALE) IBT was a 56-week, randomized, double-blind, placebo-controlled, multicenter trial in individuals with obesity who received liraglutide 3.0 mg (n = 142) or placebo (n = 140) as an adjunct to IBT.

RESULTS

At week 56, mean weight loss with liraglutide 3.0 mg plus IBT was 7.5% and 4.0% with placebo combined with IBT (estimated treatment difference [95% CI]-3.4% [-5.3% to -1.6%], P = 0.0003). Significantly more individuals on liraglutide 3.0 mg than placebo achieved ≥ 5% weight loss (61.5% vs. 38.8%; odds ratio [OR] 2.5% [1.5% to 4.1%], P = 0.0003), > 10% weight loss (30.5% vs. 19.8%; OR 1.8% [1.0% to 3.1%], P = 0.0469), and > 15% weight loss (18.1% vs. 8.9%; OR 2.3% [1.1% to 4.7%], P = 0.0311). Liraglutide 3.0 mg in combination with IBT was well tolerated, with no new safety signals identified.

CONCLUSIONS

In a primary care setting, Centers for Medicare and Medicaid Services-based IBT produced clinically meaningful weight loss at 56 weeks, enhanced by the addition of liraglutide 3.0 mg.

Lifestyle modification approaches for the treatment of obesity in adults

The U.S. Preventive Services Task Force has recommended that primary care clinicians screen all adults for obesity and provide those affected intensive multicomponent behavioral interventions. Approximately 95 million U.S. adults qualify for such care, also referred to as lifestyle modification. Using the Guidelines (2013) for Managing Overweight and Obesity in Adults (hereafter, Obesity Guidelines) as a framework, this article reviews the principal components of comprehensive lifestyle modification, which include diet, physical activity, and behavior therapy. To lose weight, the Obesity Guidelines recommend participation for 6 months in high-intensity programs that provide 14 or more counseling sessions with a trained interventionist. When provided face-to-face individual or group treatment, participants lose up to 8 kg (8% of weight) in 6 months and experience improvements in cardiovascular disease risk factors and quality of life. To prevent weight regain, the Obesity Guidelines recommend participation for 1 year in weight-loss-maintenance programs that provide at least monthly counseling. High levels of physical activity, frequent monitoring of body weight, and consumption of a reduced-calorie diet are associated with long-term weight loss. Investigators currently are seeking to increase the availability of lifestyle modification by delivering it in community-based programs, as well as on digital platforms (e.g., Internet and Smartphone). Digitally delivered programs lower costs and expand treatment reach; their efficacy is likely to improve further with the addition of new technologies for monitoring food intake, activity, and weight. Ultimately, to improve long-term weight management, individual lifestyle counseling must be joined with collective and institutional efforts to improve the nation's eating and activity environments. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

An evaluation of liraglutide including its efficacy and safety for the treatment of obesity

Introduction: The prevalence of obesity is increasing worldwide and associated conditions, particularly type 2 diabetes mellitus (T2DM), also show increasing prevalence. Lifestyle intervention should be the first line of management for obesity but additional pharmacotherapy is often required and bariatric surgery is appropriate in more severe cases. Drugs acting as glucagon-like peptide-1 receptor agonists (GLP-1RAs) developed for the management of T2DM reduce body weight and liraglutide is the first GLP-1RA to be approved for the treatment of obesity in patients with and without T2DM.Areas covered: In this review of relevant published material, the authors summarize the pharmacokinetics, pharmacodynamics, clinical efficacy and safety of liraglutide for the treatment of obesity.Expert opinion: Liraglutide effectively reduces body weight and body fat through mechanisms involving reduced appetite and lowered energy intake, independent of its glucose-lowering effects. Like most of the other medications currently available for obesity, liraglutide has some common adverse effects, although generally not serious ones. Liraglutide has additional benefits in reducing cardiovascular events in patients with T2DM but the cost and the need for daily injections may limit its use in obesity. Newer GLP-1RAs, such as semaglutide, or other drugs in development for obesity may have advantages over liraglutide.