A systematic search of the medical literature was performed on
April 6, 2007. The search, limited to human subjects and English
language journals included Ovid, UpToDate®, and the Cochrane database.
Search terms included obesity, pharmacotherapy, diabetes, insulin
resistance, hypertension, dyslipidemia, orlistat, sibutramine, and
Long-term weight loss maintenance is a challenge in the treatment
of obesity, especially in the primary care setting where time constraints
and reimbursement are major issues. The prevalence of obesity is
on the rise world wide, and is a major public health concern. There
is little doubt that this disease needs to be treated; however the
traditional strategies of weight reduction by behavior modification
and physical activity have poor long-term outcomes, primarily as
a result of lack of compliance.1 Considerable evidence
suggests that even a modest weight reduction of 5% to 10% of
initial body weight can significantly impact the morbidity and mortality
of obese patients.2 Obesity is a multifactorial disease
requiring individually tailored treatment strategies. Pharmacotherapy
plays an important role in the appropriate patient.
Body mass index (BMI) is the most practical way to evaluate weight.
It is calculated (metric formula) as follows:
- BMI = (body weight in kilograms) ÷ (height in meters)2
When measurements are recorded in pounds and inches, the following
equation may be used:
- BMI = [(body weight in pounds) × 705] ÷ (height in inches)2
BMI is relatively unaffected by height, and is highly correlated
with body fat. A BMI of 18 to 25 kg/m2 is considered
normal or ideal body weight. Patients with a BMI of 25 to 30 kg/m2 are
low risk, while those with a BMI of 30 to 35 kg/m2 are
moderate risk. Patients with a BMI of 35 to 40 kg/m2 are
at high risk, and those with a BMI above 40 kg/m2 are
at very high risk for morbidity and mortality from their obesity.
Irrespective of BMI, health risk is increased by more abdominal
fat distribution (increased waist to hip ratio) (Fig. 24-1).
Algorithm for the assessment and stepwise management
of the overweight or obese adult. *BMI and waist circumference
cutoff points are different for some ethnic groups. LDL, low-density lipoprotein;
HDL, low-density lipoprotein.
The Swedish Obese Subjects Study followed untreated obese subjects
with an average BMI of 38 kg/m2 for 2 years.3 The
2-year incidence of the following comorbidities were:
- • Hypertension: 13.6%
- • Diabetes mellitus: 6.3%
- • Hyperinsulinemia: 6.3%
- • Hypertriglyceridemia: 7.7%
- • Low serum high-density lipoprotein (HDL) cholesterol:
- • Hypercholesterolemia: 12.1%
A comparison of one of the above comorbidities, in the general
population, yielded a 29% incidence ...