Medication, Surgery Combat Biological Changes Associated with Obesity

Overweight and Sustained Obesity Require Different Approaches

By Annette M. Boyle

GOLDSTEIN

Michael Goldstein, MD

PROVIDENCE, RI — Eat less, move more has long been the mantra for weight loss. But new research indicates the mainstays of diet and exercise simply aren’t enough for many people to lose weight and keep it off.

With 78% of veterans and 86% of the DoD retiree beneficiary population classified as overweight or obese, determining how best to help current and former servicemembers and their families achieve and maintain a healthy weight has become an urgent matter. Far more than a cosmetic issue, obesity significantly increases the risk of developing chronic conditions such as diabetes and cardiovascular disease.

Current research indicates that traditional approaches to weight loss fail in large part because they do not recognize significant biological differences between individuals who are overweight and those who have sustained obesity. According to a recent comment in The Lancet Diabetes & Endocrinology, anyone who reduces calorie intake is likely to trigger certain biological adaptations evolved to prevent starvation but which today may simply frustrate dieters.1

Chronically obese individuals — but not those who are overweight — often also have other adaptations that act to preserve or increase their highest lifetime body weight. “Preadipocyte proliferation occurs, increasing fat storage capacity. In addition, habituation to rewarding neural dopamine signaling develops with the chronic overconsumption of palatable foods, leading to a perceived reward deficit and compensatory increases in consumption,” noted the authors.

For overweight veterans and servicemembers, lifestyle modifications such as consumption of less calorie dense foods and 30 minutes of exercise each day combined with behavioral counseling may be enough to achieve lasting weight loss. Programs such as the VA’s MOVE! Weight Management Program and the Army’s Body Composition Program use this model to help veterans and servicemembers achieve their weight goals.

For overweight individuals, those initiatives may be enough. “Once obesity has been established, however, body weight seems to become biologically stamped in and defended,” explained the study authors.

Pharmacotherapy Benefits

For those with sustained obesity, more is needed — not only to lose weight but also to keep it off. “Few individuals ever truly recover from obesity; rather they suffer from ‘obesity in remission,’” said lead author Christopher Ochner, assistant professor of pediatrics and psychiatry at the Icahn School of Medicine at Mount Sinai in New York.

“Obesity should be recognized as a chronic and often treatment-resistant disease with both biological and behavioral causes that require a range of medical interventions, including biologically based interventions such as pharmacotherapy or surgery as well as lifestyle modification,” Ochner added.

The VA/DoD Clinical Practice Guidelines for the Screening and Management of Overweight and Obesity updated in April 2014 recognizes that, while “lifestyle changes alone can result in weight loss for some, many overweight and obese patients need additional interventions for weight reduction. The use of pharmacologic treatment for obesity has increased in response to the increasing prevalence of obesity.”

“The Clinical Practice Guideline recommends pharmacotherapy only in conjunction with ongoing comprehensive lifestyle intervention,” Michael Goldstein, MD, associate chief consultant for preventive medicine at the VHA National Center for Health Promotion and Disease Prevention, told U.S. Medicine. Goldstein, who also is an adjunct professor at the Alpert Medical School at Brown University in Providence, RI, co-chaired the working group that developed the latest VA/DoD guidelines on obesity.

In addition, veterans who achieve their weight loss goals may be offered continued use of medication to help maintain a healthy weight. The guidelines note that only orlistat, lorcaserin and phentermine/topiramate extended release so far have been shown to be effective for a year or longer.

The Food and Drug Administration has approved all three to treat obesity in patients with body mass index (BMI) above 30 kg/m2 or with a BMI greater than 27 kg/m2 who have obesity-associated conditions such as diabetes, dyslipidemia or hypertension. Diethylpropion and phentermine are approved for use for short-term weight loss.

Despite the approval of lorcaserin and phentermine/topiramate extended release in 2012, the use of pharmacotherapy for obesity has dropped in the VA over the last five years, according to data provided by VHA Pharmacy Benefits Management:

Source: VHA Pharmacy Benefits Management

Source: VHA Pharmacy Benefits Management

The Air Force permits short-term (3-6 months) use of weight control medication in airmen with a BMI of 30 kg/m2 or greater or BMI of 27 with significant comorbid risk factors, according to Air Force Instruction 44-102 for Medical Care Management issued on March 17, 2015. The Navy provides similar guidance.

The Army, however, does not recommend the use of any medications to help soldiers lose weight. While noting that the approved medications pose minimal risk and produce weight loss of 5 to 20 pounds, “that weight loss is not usually sustained after two years,” according to Col. Robert B. Lim, MD, chief of Metabolic and Advanced Laparoscopic Surgery at Tripler Army Medical Center in Hawaii and Col. Tommy Brown, MD, general surgery consultant for the Office of the Army Surgeon General, based at Madigan Army Medical Center in Washington.

For active-duty and retired servicemembers and their dependents, costs also may limit use of weight loss medications. “Providers in the Military Health Service need to inform their patients that these drugs are not covered by the TRICARE benefit and, if patients choose to utilize this form of therapy, they must pay for these medications themselves” because of statutory prohibition of TRICARE coverage of drugs for the treatment of obesity, said Col. Stephen Phillips, deputy chief of the Defense Health Agency Clinical Support Division.

The legal restrictions on paying for drugs to treat obesity have constrained their use in the MHS to date. However, “DHA will continue to review the literature for evidence of the efficacy of pharmaceuticals in the improvement of comorbid conditions concurrent with obesity,” Phillips told U.S. Medicine. Medications — and procedures — that treat other conditions and have a side effect of causing weight loss or that improve other medical issues besides obesity are not prohibited.

Weight Loss Surgery

Consequently, “bariatric surgery is covered by TRICARE and performed in the MHS to treat comorbid conditions associated with morbid obesity,” Phillips said.

Generally, surgery may be recommended for patients with a BMI of at least 40 kg/m2 or a BMI of 35 or more with high-risk comorbidities. It may also be considered for patients with a BMI of 30 or more with either difficult to control diabetes mellitus type II or dysmetabolic syndrome X, Lim and Brown told U.S. Medicine.

Within the DoD and VA systems, weight loss surgery is available for dependent adults, retirees and VA beneficiaries, if nonoperative weight loss programs prove insufficient to reduce weight and improve comorbidities. Surgery is not an option for active duty servicemembers.

A variety of surgical types may be performed in military medical centers, VAMCs or in civilian networks with TRICARE cost-sharing. These include Roux-en-Y gastric bypass, vertical banded gastroplasty, gastroplasty, laparoscopic adjustable gastric banding, laparoscopic sleeve and duodenal switch.

The benefits of bariatric surgery include “excellent weight loss (typically 50% of excess body weight), resolution or improvement of most comorbid disease including diabetes, hypertension, depression, gastroesophageal reflux disease, obstructive sleep apnea, osteoarthritis, hyperlipidemia, renal dysfunction, non-alcoholic fatty liver disease, polycystic ovarian syndrome, stress incontinence and infertility,” Lim and Brown said. In addition, they noted that the surgery reduces the lifetime risk of a myocardial infarction and cerebral vascular accident/stroke and may lower the risk of developing cancer while improving patients’ quality of life.

Goldstein also noted that recent research found obese veterans who had undergone bariatric surgery demonstrated lower all-cause mortality at five years and up to 10 years following the procedure. 2

1 Ochner CN, Tsai AG, Kushner RF, Wadden TA. Treating obesity seriously: when recommendations for lifestyle change confront biological adaptations. Lancet Diabetes Endocrinol. 2015 Apr;3(4):232-4.

2Arterburn DE, Olsen MK, Smith VA, Livingston EH, Van Scoyoc L, Yancy WS Jr, Eid G, Weidenbacher H, Maciejewski ML. Association between bariatric surgery and long-term survival. JAMA. 2015 Jan 6;313(1):62-70.

From the VA/DOD Obesity Pocket Card

Comments (2)

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  1. Bob Dieter says:

    I’ve gone through the MOVE program at the VA and lost 20 pounds and stopped losing. The problem is that I was on a 2000 cal diet, have physical limitations and was unable to exercise. These other options were not even considered so I’m not sure what the reluctance is to prescribe these medications. Thank you for the article and I’ll be sure to address it with my PCP when I see him later this month.

  2. Stephen Casowitz, PA-C says:

    The article mentions that weight loss surgery is available through the VA system. I desperately want to know, in which VA facilities is this happening?? I work at the Seattle VA and this is not available for our patients to the best of my knowledge. In fact, I am not aware of any VA facilities in the Pacific Northwest region that offer surgical intervention for obesity. However, it certainly should available throughout the VA system, as it would lead to better overall health status and quality of life for a tremendous segment of the VA patient population. In addition, it would also save the VA money in the long run. The new Veterans Choice Program really needs to include bariatric surgery for those VA patients who are good candidates.

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