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Obesity: Definition, Comorbidities, Causes, and Burden
Caroline M. Apovian, MD, FACP, FACN
The Role of Managed Care Organizations in Obesity Management
Kenneth L. Schaecher, MD, FACP, CPC
Impact of Obesity Interventions on Managed Care
Impact of Obesity Interventions on Managed Care

Obesity: Definition, Comorbidities, Causes, and Burden

Caroline M. Apovian, MD, FACP, FACN
Obesity has been shown to increase the risk of chronic conditions such as rheumatoid arthritis (RA). A meta-analysis of 13 studies, involving 400,609 participants, found that the relative risk (RR) of RA was 1.21 (95% CI, 1.02-1.44) for patients who were obese and 1.05 (95% CI, 0.97-1.13) for patients who were overweight. A 13% increase in the risk of RA was seen for every 5 kg/m2 increase in BMI.58

Nonallergic Rhinitis

Adults and children who are overweight or obese are at an increased risk of nonallergic rhinitis, with adjusted OR of 1.43 (95% CI, 1.06-1.93) for adults and 0.88 (95% CI, 0.63-1.22) for children.59 However, being overweight or obese does not appear to increase the risk of allergic rhinitis.

Major Depressive Disorder

Obesity is also a risk factor for major depressive disorder (MDD). For women with a baseline BMI of 30 or higher, the odds of MDD rose significantly (OR, 5.25; 95% CI, 1.41-19.58) independent of other risk factors such as age, education, prior depressive symptoms, marital status, chronic disease, low social support, and financial strain.60 Persons with a higher BMI showed a slightly increased risk of developing depression (over a 6-year study period).61 However, no relationship has been found between BMI and the persistence of depres-sion. A temporal connection was also reported between obesity and general anxiety disorder (GAD). Women with a BMI of 30 or higher had a greater chance of devel-oping GAD (OR, 6.27; 95% CI, 1.39-28.16); this was not found for women with a baseline BMI of 25 or higher (OR, 2.15; 95% CI, 0.78-5.93).60 Similarly, a meta-analysis showed that baseline excess weight was associated with depression in people 20 years or older, but not younger.62 People who were obese had a 55% increased risk of depression, and people who were depressed had a 58% increased risk of becoming obese.

Cancer

Additionally, patients who are obese have an increased risk of cancer. Prospectively collected data from the UK Clinical Practice Research Datalink were evaluated, including BMI values and the prevalence of 22 different cancers for 5.2 million people. The mean BMI of the pop-ulation was 25.5 kg/m2; 3.8% developed any cancer, and 3.2% developed 1 of the 22 cancers recorded in the study. Thirteen of the 22 cancers were associated with being overweight or obese; 41% of cases of uterine cancer and more than 10% of gallbladder, kidney, liver, and colon cancers were attributable to being overweight or obese. Higher BMI was positively correlated with an increased risk of uterine, gallbladder, kidney, cervical, and thyroid cancers, along with leukemia, and positive associations were seen with liver, colon, ovarian, and postmenopausal breast cancers.63 A similar relationship between obesity and cancer was observed in cancer-related deaths in the United States. Death from cancer was attributed to being overweight, and obesity ranged from 4.2% to 14.2% for men and 14.3% to 19.8% for women. If people could potentially maintain a BMI under 25 kg/m2, an estimated 90,000 deaths per year from cancer could be avoided.64

Pharmacotherapy for Other Conditions and Associated Weight Gain

Several medication classes have been associated with weight gain, including antidepressants, atypical antipsychotics, antiepileptic drugs, and beta-blockers.

Antidepressants

Common treatments of MDD may increase the risk of obesity. Grundy and colleagues reported that women who took antidepressants were more likely to be obese (OR, 1.71; 95% CI, 1.16-2.52).65 Weight gain appears to occur in a large proportion of patients taking antidepres-sants. One study of 362 patients (mostly women) showed that antidepressant use promoted weight gain in 55.2% of patients, with a mean gain of 4.97 ± 6.16 kg, usually occurring in the first 3 months of treatment. Treatment with escitalopram, sertraline, or duloxetine is associated with significant weight gain; patients gain 7% or more from their baseline weight in the first 3 months of use. Mirtazapine, citalopram, venlafaxine, or paroxetine is associated with a 20% or higher weight gain.66

Polypharmacy, either adding a second antidepressant or an atypical antipsychotic, may become necessary for the management of MDD. Examining antidepressant plus anti-depressant co-treatment (AD + AD) versus antidepressant monotherapy (AD) showed that AD + AD therapy is asso-ciated with an increased risk of weight gain (RR, 3.15; 95% CI, 1.34-7.41; P = .009). Specific classes of antidepressants are associated with greater weight gain than others. For example, the addition of noradrenergic and specific sero-tonergic antidepressants (NaSSAs) to selective serotonin reuptake inhibitors (SSRIs) is associated with a greater incidence of weight gain than SSRI therapy alone. The RR of 7% or higher weight gain was 3.81 (95% CI, 1.37-10.55).67

Antipsychotics

Antipsychotics used as adjunctive treatment in MDD are associated with weight gain, diabetes, and lipid disorders. A randomized study examining the effectiveness of atypical antipsychotics reported a weight gain of more than 7% from baseline in 30% of patients taking olanzap-ine, 16% of patients taking quetiapine, 14% of patients taking risperidone, 12% of patients taking perphenazine, and 7% of patients taking ziprasidone.68 Long-term treatment, even at low doses, can lead to increases in blood lipids, triglycerides, and glucose, eventually leading to weight gain.69 It is recommended that potential weight gain be considered when selecting an antipsychotic and that patients be informed of the estimated weight gain for the medications.15 Once an antipsychotic is prescribed, clinical guidelines recommend that clinicians monitor a patient’s height, weight, BMI, and waist circumference throughout treatment with antipsychotics; if the patient gains 5% or more of his/her baseline weight, the clinician should consider a different antipsychotic.70

Sulfonylureas, Thiazolidinediones, and Insulin

Many treatments for T2D are associated with weight gain, with the potential of patients gaining up to 10 kg within 6 months after the start of treatment.15 Weight gain of 3.0 kg has been reported for thiazolidinediones; sulfonylureas, 1.12 kg; and insulin, 1.7 to 2.5 kg.15,71 Other classes of medications, such as sodium-glucose cotrans-porter 2 (SGLT-2) inhibitors, GLP-1 receptor agonists, and dipeptidyl peptidase 4 (DDP4) inhibitors, have been shown to be weight-reducing or weight-neutral therapies. Metformin is also associated with weight loss. Patients who are obese and require treatment for T2D should be prescribed weight-loss or weight-neutral medications as first- or second-line treatment. It is recommended that patients with obesity and T2D who require insulin also be prescribed metformin, pramlintide, or GLP-1 agonists to offset insulin-associated weight gain.15

Antiepileptic Drugs

Valproic acid, carbamazepine, and gabapentin are antiepileptic medications that are associated with weight gain. The most significant weight gain has been reported with valproic acid, in the range of 5 to 49 kg.72

Corticosteroids

Steroid therapy is essential to the treatment of inflam-matory disorders; however, steroids are associated with weight gain. Glucocorticosteroid therapy is associated with a 4.4% increase in weight after a year of treatment, and that weight gain is often maintained even after gluco-corticosteroid therapy is stopped.73 Treatment guidelines recommend against chronic steroid treatment to avoid weight gain in individuals who are overweight or obese.15

Beta-blockers

Beta-blockers, which are used for migraine and myocardial infarction prophylaxis and for the management of hypertension and heart failure, have also been associated with a mean weight gain of 1.2 kg.72 A study examined the effects of beta-blockers on weight loss and reduction of waist circumference in 3582 patients (173 were taking beta-blockers) involved in an intensive calorie-restriction program of 900 kcal/day. Participants taking beta-blockers lost a mean 0.67 kg less than par-ticipants in the control group and had a smaller decrease in waist circumference (–24.2 vs –25.2 cm, respectively).74 The authors recommend that alternate hypertensive treatment should be considered for patients with obesity. Treatment guidelines recommend a selective or nonse- lective beta-blocker (eg, carvedilol or nebivolol) because these agents have less potential of weight gain.15

Conclusion

The paradigm shift from thinking of obesity as a character flaw to an understanding that it is a disease is monumental. Hopefully, this will motivate healthcare professionals to be proactive and intervene sooner when individuals are identified at risk or meet the definition of obesity. Prescribers and pharmacists should be aware of the pathophysiology of obesity to understand the rationale for medication therapy. Awareness of the risk factors of obesity, especially those that are preventable, is important so that clinicians can counsel patients on how to avoid or minimize them. Obesity is a serious public health concern, and the associated financial and health consequences to Americans can be addressed by prescribers and pharmacists.

Obesity is a complex interaction between multiple genetic, socioeconomic, and cultural factors that also are associated with existing or resulting comorbidities and their treatments. The prevalence of obesity continues to be high, as are associated comorbidities and healthcare costs. Early intervention and effective treatment of obesity are needed to reduce costs and improve outcomes for these patients. 

Author affiliation: Boston Medical Center and Boston University School of Medicine, Boston, MA.

Funding source: This activity is supported by educational grants from Novo Nordisk and Takeda Pharmaceuticals U.S.A., Inc.

Author disclosure: Dr Apovian has disclosed being a consultant for Amylin, Arena, EnteroMedics, Gelesis, Johnson and Johnson, Merck, Novo Nordisk, Nutrisystem, Orexigen, Sanofi-Aventis, Scientific Intake, Takeda, and Zafgen; she also reports research funding from Amylin, Aspire Bariatrics, the Dr. Robert C. and Veronica Atkins Foundation, GI Dynamics, Lilly, MetaProteomics, MYOS Corporation, Orexigen, Pfizer, and Sanofi-Aventis, as well as owning stock in Science Smart LLC.

Authorship information: Concept and design, drafting of the manuscript, critical revision of the manuscript for important intellectual content, and supervision.

Address correspondence to: caroline.apovian@bmc.org.
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