What is the recommended management for patients with obesity, insulin resistance, hypertension, and dyslipidaemia?

Management of Patients with Obesity, Insulin Resistance, Hypertension, and Dyslipidemia

For patients with obesity, insulin resistance, hypertension, and dyslipidemia, the most effective management approach is a comprehensive lifestyle intervention combined with GLP-1 receptor agonist-based pharmacotherapy, with additional targeted medications for specific cardiometabolic abnormalities. 1

Initial Assessment and Risk Stratification

• Calculate and document BMI at each visit 1
• Asian Americans have lower BMI cutoff points for overweight (≥23 kg/m²) and obesity (≥27.5 kg/m²) 1
• Assess for obesity-related comorbidities (diabetes, hypertension, dyslipidemia, sleep apnea)
• Screen for social determinants of health affecting treatment adherence
• Review anthropometric measurements and laboratory tests to classify obesity and cardiometabolic risk

Lifestyle Intervention (Foundation of Treatment)

Dietary Approach

• Implement high-intensity (≥16 sessions in 6 months) dietary intervention 1
• Target 500-750 kcal/day energy deficit 1
• Focus on reducing total caloric intake (1200-1500 kcal/d for women; 1500-1800 kcal/d for men) 1
• Emphasize Mediterranean-style diet pattern with:
  • Low intake of saturated fats (<7% of calories) 1
  • Low cholesterol intake (<200 mg/day) 1
  • Increased consumption of fruits, vegetables, whole grains 1
  • Reduced processed foods, salt, and sugar 1

Physical Activity

• Prescribe at least 150 minutes/week of moderate-intensity aerobic activity plus resistance training 1
• Progress to 200-300 minutes/week for weight maintenance 1
• Any increase in physical activity is beneficial, even short 5-10 minute walks 1

Behavioral Therapy

• Include weight self-monitoring, problem-solving strategies 1
• Address sleep hygiene (aim for 7-9 hours nightly) 1
• Smoking cessation and alcohol moderation (≤1 drink/day for women, ≤2 drinks/day for men) 1

Pharmacotherapy

Weight Management Medications

• Initiate if ≥7% weight reduction not achieved with lifestyle alone 1
• First-line: GLP-1 receptor agonist-based medications (semaglutide, liraglutide, tirzepatide) 1
  • Provide 15-25% weight reduction 1
  • Improve cardiovascular outcomes in patients with established CVD 1
  • Tirzepatide shows greatest effect with mean weight loss of 21% at 72 weeks 1

Antihypertensive Therapy

• First-line: Renin-angiotensin system blockers (ACE inhibitors or ARBs) 1
  • Associated with lower incidence of diabetes compared to other antihypertensives
  • Favorable effects on organ damage
• Second-line: Add calcium channel blockers 1
  • Metabolically neutral
  • Combination with RAS blockers associated with lower diabetes incidence
• Third-line: Consider low-dose thiazide diuretics 1
• Avoid beta-blockers unless specifically indicated, as they can adversely affect:
  • Incidence of new-onset diabetes
  • Body weight
  • Insulin sensitivity
  • Lipid profile 1

Dyslipidemia Management

• Statin therapy based on cardiovascular risk assessment
• Target LDL-C reduction according to risk category
• Consider ezetimibe or PCSK9 inhibitors for additional LDL-C lowering if needed
• For hypertriglyceridemia: optimize lifestyle, consider omega-3 fatty acids 1

Insulin Resistance Management

• GLP-1 receptor agonists improve insulin sensitivity 1
• Consider metformin if diabetes or prediabetes is present
• SGLT2 inhibitors if appropriate (especially with cardiovascular or renal disease) 1

Monitoring and Follow-up

• Close follow-up every 4-6 weeks initially 1
• Monitor:
  • Weight and BMI
  • Blood pressure
  • Glycemic control
  • Lipid parameters
  • Medication adherence and side effects
• Adjust treatment plan as needed based on response
• For patients who achieve short-term weight loss goals, implement long-term (≥1 year) weight maintenance programs 1

Special Considerations

• Weight loss of 5-10% can improve cardiometabolic parameters, but larger weight losses produce greater benefits 1
• Even modest weight loss (3-5%) may lead to clinically meaningful reductions in cardiovascular risk factors 1
• Weight loss-induced improvements in glycemia are most likely to occur early in the natural history of type 2 diabetes 1
• The combination of a RAS blocker and calcium antagonist is associated with lower diabetes incidence than conventional treatment with beta-blockers 1

By implementing this comprehensive approach targeting obesity, insulin resistance, hypertension, and dyslipidemia simultaneously, clinicians can significantly reduce cardiovascular risk and improve long-term outcomes in these patients.