What is the best approach to manage obesity in a young patient with significant weight gain?

From the Guidelines

The best approach to manage obesity in a young patient with significant weight gain is a comprehensive, multidisciplinary strategy that includes lifestyle modifications, medical evaluation, and potential pharmacological or surgical interventions, with a focus on establishing sustainable healthy habits rather than rapid weight loss. Given the patient's age (21 years old) and significant weight gain (400 lbs) starting at a young age (10-11 years old), it is essential to consider the long-term health consequences of obesity, such as cardiovascular disease, type 2 diabetes, and mental health issues 1. The patient's BMI is likely to be above 35, given the significant weight gain, which would categorize them as having severe obesity. According to the expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents, for individuals with a BMI ≥ 95th percentile, a specific assessment for comorbidities is strongly recommended, and a comprehensive multidisciplinary lifestyle weight-loss program is recommended for intensive management 1. Some key points to consider in the management of obesity in this patient include:

• A thorough medical evaluation to identify any underlying conditions contributing to weight gain, such as hypothyroidism, Cushing's syndrome, or medication side effects
• Implementation of lifestyle modifications, including a balanced, calorie-controlled diet emphasizing whole foods, regular physical activity (aiming for 60 minutes daily), and behavioral therapy to address eating patterns and psychological factors
• Family involvement, with parents and caregivers modeling healthy behaviors and creating a supportive home environment
• Potential pharmacological interventions, such as orlistat, under medical supervision
• Consideration of bariatric surgery if other interventions have failed and the patient has completed or nearly completed physical growth The most recent study on obesity management, published in 2023, emphasizes the importance of a multidisciplinary collaborative approach, involving various healthcare specialties, to facilitate and help maintain weight loss 1. This approach should include a dietician and/or nutritionist, an exercise specialist or physiotherapist, a psychologist, psychiatrist, or behavioral therapist, and an obesity nurse and/or educator. Regular monitoring of growth, development, and potential nutritional deficiencies is essential throughout treatment. By prioritizing a comprehensive, multidisciplinary strategy, healthcare providers can help young patients with significant weight gain establish sustainable healthy habits and reduce the risk of long-term health consequences.

From the FDA Drug Label

Phentermine Hydrochloride, USP 15 mg and 30 mg is indicated as a short-term (a few weeks) adjunct in a regimen of weight reduction based on exercise, behavioral modification and caloric restriction in the management of exogenous obesity for patients with an initial body mass index greater than or equal to 30 kg/m 2, or greater than or equal to 27 kg/m 2 in the presence of other risk factors (e.g., controlled hypertension, diabetes, hyperlipidemia).

The best approach to manage obesity in a young patient with significant weight gain is to use a regimen of weight reduction based on exercise, behavioral modification, and caloric restriction.

• Phentermine may be considered as a short-term adjunct in this regimen for patients with a BMI greater than or equal to 30 kg/m2 or greater than or equal to 27 kg/m2 in the presence of other risk factors.
• However, phentermine is not recommended for use in patients 16 years of age and under 2. It is essential to weigh the potential benefits of phentermine against its possible risk factors, such as primary pulmonary hypertension and valvular heart disease 2.

From the Research

Obesity Management Approach

The best approach to manage obesity in a young patient with significant weight gain involves a multifaceted personalized treatment plan, including lifestyle intervention, pharmacotherapy, and potentially surgical or endoscopic procedures 3.

Lifestyle Intervention

Lifestyle intervention should include dietary changes, increased physical activity, and behavioral interventions 3. However, compensatory mechanisms may act against weight loss, and recent changes to Food and Drug Administration-approved antiobesity medications should be considered 3.

Pharmacotherapy

There are currently five Food and Drug Administration-approved medications for the treatment of obesity: orlistat, phentermine/topiramate, naltrexone/bupropion, liraglutide 3.0 mg, and semaglutide 2.4 mg 4, 5, 6, 7. These medications can be classified according to their mechanisms of action, including:

• Modifying digestive tract absorption (orlistat)
• Centrally acting drugs (phentermine-topiramate and naltrexone-bupropion)
• Nutrient-stimulated hormone-based medications (liraglutide, semaglutide, and tirzepatide)

Surgical and Endoscopic Options

Surgical options, such as bariatric surgery and endoscopic surgery, can induce more durable weight loss than pharmacotherapy or lifestyle interventions alone 4. However, patients often experience weight regain and weight loss plateau after surgery, and the addition of multimodal or multihormonal pharmacotherapy may be necessary to address these challenges 4.

Key Considerations

When selecting an anti-obesity medication, the patient's clinical and biochemical profile, co-morbidities, and drug contra-indications should be taken into account, as well as the expected degree of weight loss and improvements in cardio-renal and metabolic risk 6. The choice of medication should be personalized to the individual patient, and ongoing monitoring and adjustment of the treatment plan may be necessary to achieve optimal outcomes.

Available Medications

Some of the available medications for obesity management include:

• Orlistat: associated with 3.1% greater weight loss compared to placebo 5
• Phentermine-topiramate: associated with 8.0% greater weight loss compared to placebo 5
• Naltrexone-bupropion: associated with 4.1% greater weight loss compared to placebo 5
• Liraglutide: associated with 4.7% greater weight loss compared to placebo 5
• Semaglutide: associated with 11.4% greater weight loss compared to placebo 5
• Tirzepatide: associated with 12.4% greater weight loss compared to placebo 5