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Decision-making in the management of obesity: a scoping review protocol

Skulsky, Samuel Lamarre 1 ; Kolozsvari, Oana 2 ; Stacey, Dawn 3,4 ; Shorr, Risa 5 ; Gu, Jeffrey 6

1 Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada

2 The Ottawa Hospital Bariatric Centre of Excellence, Ottawa, ON, Canada

3 Department of Clinical Epidemiology, University of Ottawa, ON, Canada

4 Ottawa Hospital Research Institute, Ottawa, ON, Canada

5 Learning Services, The Ottawa Hospital, Ottawa, ON, Canada

6 Department of Surgery, University of Saskatchewan, Saskatoon, SK, Canada

Correspondence: Samuel Lamarre Skulsky, [email protected]

The authors declare no conflict of interest.

Objective:

This scoping review will evaluate the current published literature on decision-making in obesity management.

Introduction:

Obesity is increasing in incidence worldwide. Although indications have been established for a variety of available treatment modalities, treatment selection must also factor in patient preferences, clinician expertise, and resource availability. Such considerations are crucial given the exponential expansion of new surgical techniques and pharmacologic options in the last decade. Although literature exists for decision-making on various obesity management topics, there are no scoping reviews systematically mapping the literature. This scoping review is timely given that the treatment of obesity has evolved into a multidisciplinary endeavor with myriad management decisions that both patients and clinicians must navigate.

Inclusion criteria:

The review will consider for inclusion full-text primary studies, published in English from the year 2000 onwards, pertaining to decision-making in obesity management for health care providers involved in obesity management for patients aged ≥18 years.

Methods:

This scoping review will be conducted in accordance with the JBI methodology for scoping reviews. Embase (Elsevier), MEDLINE (PubMed), Scopus (Elsevier), Web of Science (Clarivate), CINAHL Complete (EBSCO), PsycINFO (EBSCO), and Cochrane Central (Wiley) will be systematically searched using a predefined strategy. Two independent reviewers will conduct a 3-tiered screen of identified articles, with a third reviewer resolving disputes. Data extraction will be performed using a predefined, yet flexible form. Descriptive summaries and mapping will be provided for included studies. Available evidence and knowledge gaps will be identified and summarized as they relate to specific concepts, populations, and contexts in obesity management decision-making.

Introduction

Obesity, defined as a body mass index (BMI) greater or equal to 30 kg/m 2 , is a chronic disease increasing in prevalence worldwide. 1 There are multiple treatment modalities for managing obesity, including surgery, pharmacological treatments, medical management, as well as behavioral modifications. Each treatment modality varies in efficacy, complications, side effects, long-term follow-up requirements, and cost, all of which may affect treatment choice. 2 These modalities can be used individually or in combination. Patients and clinicians must navigate the increasing array of management options to select an appropriate treatment plan that aligns with the patients’ values and overall goals. Improved decision-making processes may lead to improved treatment decisions and patient satisfaction.

Pharmacological agents can affect weight loss and ameliorate obesity-related comorbidities, often as adjuncts to other treatment modalities. Liraglutide and semaglutide are glucagon-like peptide-one (GLP-1) receptor agonists that demonstrate efficacy in producing clinically significant weight loss in patients with or without concomitant diabetes. 3 The combination drug naltrexone/bupropion also offers good initial weight loss. 4 In contrast to surgery, data on long-term weight loss for these medications are lacking. However, 1-year outcomes demonstrate 18%, 24%, and 15% excess weight loss for liraglutide, semaglutide, and naltrexone/bupropion, respectively. 3,5,6 However, pharmacological options may be limited by side effects and require long-term adherence, thus carrying an associated lifelong financial cost. Discontinuation of pharmacological therapy leads to weight regain and reversal of comorbidity resolution. 7

Medical management is another approach for obesity management. Although inconsistent, the literature generally equates “medical management” to medically supervised diets. Medical management can provide rapid weight loss for preoperative optimization (both bariatric and non-bariatric procedures) and is less invasive than bariatric surgery or pharmacotherapy. 8,9 Medical management focuses on caloric restriction, whether through balanced low-calorie diets, carbohydrate or fat restriction, increased protein intake combined with reduced calories, or intermittent fasting. 9 The most consistently successful diet is the very low-calorie diet (VLCD), constraining patients to 200 to 800 daily calories. In 1 review article, initial weight loss (%IWL) for the VLCD at 6 and 12 months was 16% and 10%, respectively. 10 However, VLCDs may not confer superior long-term weight loss compared with conventional diets. In a 2012 meta-analysis of VLCDs, mean %IWLs of 6% and 5% were reported for VLCDs and LCDs, respectively (mean follow-up 1.9 +/− 1.6 years). 11 Side effects from dietary approaches include hair loss, sensation of being cold, and thinning of the skin, among other symptoms. 9

Behavioral modification (also known as behavioral therapy) is another approach, used either as a primary treatment option or incorporated into a multi-modal treatment program. Behavioral modification aims for sustained weight loss by helping patients modify patterns of food intake and physical activity as well as helping address cues and/or environmental stimuli that may prompt overeating. 8 Behavior modification has been shown to improve weight loss achieved with other treatment modalities, such as dietary and pharmacological therapy. 12 Behavioral modification is provided in multiple contexts: patients may utilize established treatment programs involving direct interaction with registered dietitians, psychiatrists, and psychologists, although self-help or commercial weight-loss programs exist as do technology-based approaches such as mobile applications. 13 Regardless of the specific modality, patient adherence is a key determinant of successful weight loss when applying behavior modification. In the Look AHEAD study, obese adults with type 2 diabetes mellitus assigned to intensive behavioral modification demonstrated greater clinically significant weight loss 8 years later compared with patients assigned to upfront support groups and basic education. 14

Bariatric surgery is the most effective treatment for obesity and facilitates remission of obesity-associated comorbidities. 15 It is typically reserved for patients with a BMI ≥ 40 or for patients with a BMI ≥ 35 with obesity-related comorbidities. The 2 most common operations are the vertical sleeve gastrectomy (VSG) and the Roux-en-Y gastric bypass (RYGB). 16 However, other bariatric procedures are gaining popularity, such as the duodenal switch. 16,17 Of the obesity management options, surgery offers the best long-term sustained weight loss and comorbidity resolution. Percent excess weight loss at 10 years is approximately 60%, 56%, and 74% for the VSG, RYGB, and duodenal switch, respectively. 18 Ten-year diabetes remission rates for RYGB and duodenal switch were 25% and 50%, respectively. 15 Although contemporary 30-day post-operative mortality rates and post-operative morbidity rates are 0.2% and 3%, respectively, 19 patients still assume this risk. Furthermore, each surgery carries its own complication profile and requires permanent adjustments, such as dietary changes and lifelong vitamin supplementation.

Decision-making in the management of obesity should ideally account for multiple factors, starting with which treatment modalities to pursue, while incorporating patient preferences and values along with those of their health care providers. Additional factors to consider include patient medical/surgical history, willingness to implement dietary and behavioral changes, expected outcomes, treatment risk profiles/side effects, ability to participate in pre- and post-operative care, fitness for surgery, as well as clinician expertise, financial considerations, and health care system resource constraints.

An important concept in decision-making is shared decision-making (SDM), a collaborative process in which both the health care provider and the patient participate in deciding on a particular treatment. The health care worker, guided by empirical evidence, provides an overview of available treatments and their alternatives, expected outcomes, and risks. Ideally, this facilitates the selection of a treatment aligned with the patient's core values, preferences, and personal or cultural beliefs. 20 Nevertheless, research suggests that SDM is inconsistently applied in health care 21 ; however, within the field obesity management, researchers and clinicians are highlighting the applicability of SDM. Already, SDM has been studied for various decisions required in obesity management, including the decision to initiate treatment, 22 initiate healthy behavioral changes, 23 choose a specific surgical procedure, 24 and select appropriate pharmacotherapy. 25

Clinicians also grapple with patient misconceptions and health care providers who may act as “barriers” to pursuing appropriate treatment. For example, 1 study of family physicians revealed that 52% were not aware that the contemporary mortality rate is less than 1% for bariatric surgery. This is striking given that, in the same study, the most common reason for non-referral was “potential for complications and death.” 26 Similarly, patient misconceptions surrounding obesity management are common. With bariatric surgery, for example, a lack of familiarity with post-operative morbidity and mortality rates, surgical candidacy, realistic weight loss expectations, and post-operative lifestyle changes are frequently encountered. 27 As a result, a patient's desired treatment and outcomes might not align. For example, 1 study reported on a subgroup of patients desiring a laparoscopic adjustable gastric band despite having “maximum weight loss” as their stated top priority; laparoscopic adjustable gastric bands do not provide the greatest degree weight loss. 24 This exemplifies the need for patient education in addition to determination of a patient's preferential values when selecting an appropriate treatment.

Patient decision aids are interventions that facilitate SDM, providing information on options, benefits and harms, and helping patients clarify their values for outcomes. 28 In addition to helping patients assume an active role in decision-making, decision aids improve their knowledge and set realistic expectations, lower decisional conflict, and enhance agreement between the option chosen and patients’ values. 29 Within the field of obesity management, the study of decision aids has focused on surgical decision-making, 29 although some research addresses multiple treatment modalities. 30,31

Given the expanding list of management options for obesity that both clinicians and patients must navigate, treatment decisions are becoming increasingly complex. Thus, our scoping review is timely and aims to determine the current body of knowledge on decision-making in obesity management. Specifically, we seek to clarify the types of decisions that have been studied, including referral versus treatment decisions from primary care providers, decisions on which categories of treatment to pursue (eg, pharmacotherapy vs surgical management or both), and deciding on treatment options within a category (eg, which surgery to choose). In clarifying the types of decisions explored in the literature, we also wish to determine the health care contexts in which these decisions have been studied, ranging from primary to specialist care. We also wish to identify studies on decision aids and SDM in obesity management, and determine which of the abovementioned types of decisions were examined.

As described, both patients and health care providers may misunderstand the risks and benefits associated with specific obesity treatment modalities. 24,26,27 Furthermore, other factors may hinder patients from pursuing specific treatments, including financial burden or the inability to quit smoking (smoking cessation is a common requirement for undergoing bariatric surgery). 32 This scoping review seeks to identify the existing primary studies on these barriers to optimal obesity management.

In addressing these questions, this scoping review ultimately aims to identify knowledge gaps in decision-making research for obesity management, with the goal of directing future research to decisions that have been understudied. Additionally, in identifying the barriers to obesity management reported in the literature, we hope to highlight factors that either require further study or could be considered by future researchers for incorporation into new decision-making tools. A search of Google Scholar, MEDLINE (PubMed), and JBI Evidence Synthesis did not identify any published or in-progress scoping reviews that address this topic in the manner proposed by our current protocol. The value of undertaking this scoping review is that it can help direct future research on decision-making in obesity and facilitate future care for patients suffering from a disease that is reaching epidemic proportions.

Review questions

What is the status of current knowledge in the published literature about decision-making in the management of obesity in relation to those involved in treatment decisions (eg, patients, clinicians) and the various clinical settings in which management decisions are made?

Sub-questions include:

i) In the setting of obesity management, how is decision-making defined in the literature and what types of decisions have been examined?
ii) What published literature exists on obesity management decision aids and what treatment modalities are addressed in these aids?
iii) What published literature exists on SDM for patients and clinicians in obesity management and who are the individuals under study?
iv) What barriers to decision-making are reported by the obesity management literature?

Inclusion criteria

The inclusion criteria have been developed using the PCC framework 33 and are outlined below.

Participants

This review will include studies examining individuals involved in obesity management, either as clinicians or as recipients of treatment. Relevant individuals include adult patients (≥ 18 years of age) living with obesity (BMI ≥ 30), primary care providers, bariatric medicine clinicians, bariatric surgeons, and multidisciplinary allied health staff, including, but not limited to, psychiatrists, psychologists, nurses, and dietitians. The reason for excluding patients ≥ 18 years is that, despite increasing acceptance, controversy still exists surrounding bariatric surgery for minors, with many pediatric practitioners reporting that they would not refer their patients for surgical consultation. 34 Furthermore, pediatric patients face relatively greater challenges with access to bariatric surgical programs compared with their adult counterparts. 34 Although it is just 1 option for managing obesity, the difference in attitudes and access to bariatric surgery between minors and adults is such that a scoping review on decision-making in obesity management for pediatric patients should be a separate undertaking.

This review will examine studies on decision-making in obesity management. In general, decision-making is a cognitive process of choosing 1 course of action from several possibilities. 35 This will be our working definition when considering whether a potential source is addressing decision-making. When making a decision, the best available evidence is applied within the constraints of available clinical expertise and resources, while accounting for patient and provider preferences. In medical literature, a precise taxonomy for the various kinds of decisions made in health care is not consistently applied, 36 therefore, a study's use of the term “decision-making” can refer to myriad different types of decisions (eg, treatment decisions, choosing an investigation, choosing to consult a specialist). As such, this scoping review also aims to clarify what exactly is being studied in the decision-making literature within the field of obesity management.

A sub-categorization of decision-making important to this review is the concept of SDM. In contrast to “decision-making,” SDM is a more concrete term that has been defined as a collaborative process in which both the clinician and patient participate in arriving at a particular treatment. The clinician, informed by empirical evidence, provides an overview of available treatments and the associated risks and benefits while the patient shares their core values, preferences, and personal or cultural beliefs in order to arrive at a mutually shared treatment decision. 20 Similarly to SDM, “decision aids” is a well-defined term, and is considered interventions that facilitate SDM by making explicit the decision, providing information on options, benefits, and harms, and helping patients clarify their values for outcomes. 28

The concept of treatment modalities for obesity also requires definition to ensure clarity and a common language for the scoping review. For example, “medical management of obesity” is inconsistently defined; in the literature it has been used interchangeably to refer to medically supervised diets or pharmacological treatments. For the purposes of this review, we will categorize treatment modalities as falling into one of the following categories: surgical management, pharmacological treatments, medical management (meaning medically supervised diets), and behavioral interventions (inclusive of psychiatric and psychological management, and exercise therapy).

For the purposes of this review, a “barrier” to decision-making will be defined as any factor that might affect pursual of evidence-based management of obesity. For example, a barrier could be a primary care physician's misunderstanding of complication rates for bariatric surgery or patient unfamiliarity with treatment options.

This review aims to capture decision-making in obesity management in all health care settings where care may be provided, on a continuum from primary to quaternary care. For example, in a primary care context, possible decisions may be whether to initiate lifestyle interventions or to refer the patient to a specialized treatment center. At the tertiary level, the decisions may be focused on choosing a combination of surgical, pharmacological, medical, and behavioral interventions. This scoping review will not focus on decision-making research in the context of experimental treatments and will thus be restricted to research focusing on currently accepted treatments. Observational decision-making research, as well as controlled experiments on decision-making for currently accepted treatments, will be considered. From a geographic/cultural perspective, we will not consider decision-making research examining traditional, natural, or cultural treatment modalities without peer-reviewed evidence of their efficacy. Two of the authors (JG, NK) of this scoping review protocol are experts in obesity management; if they are unable to ascertain whether a particular treatment is sufficiently evidence-based, we will consult our multidisciplinary colleagues to determine whether the treatment is backed by evidence or is commonly used.

Types of sources

This scoping review will consider primary research studies with quantitative, qualitative, and mixed methods study designs. Opinion articles, letters to the editor, book chapters, systematic reviews, narrative reviews, clinical reviews, and consensus guidelines will not be included. However, all sources that are captured by our search will have their references examined for potential primary studies to include.

The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews. 33

Search strategy

The search strategy will aim to locate published primary studies. In collaboration with a research librarian familiar with academic and clinical health care research, an initial limited search of Embase (Elsevier), MEDLINE (PubMed), Scopus (Elsevier), Web of Science (Clarivate), CINAHL Complete (EBSCO), PsycINFO (EBSCO), and Cochrane Central (Wiley) was undertaken using preliminary keywords relating to our population, context, and concepts described above. A list of the text words contained in the titles and abstracts of relevant articles, as well as the index terms used to describe those words, was compiled. Synonyms and interchangeable terms for these keywords were also collected. Using these terms, we performed a search of CINAHL Complete (EBSCO; see Appendix I). Gray literature and/or media will not be included; this scoping review is focused on peer-reviewed literature that is readily accessible to those with interest in decision-making research. The reference lists of articles selected for full-text review will be screened for additional papers. The study reviewers intend to contact authors of primary studies if information relevant to our planned data extraction is missing.

We will restrict our final analysis to articles published in English as a matter of convenience and to avoid interpretative errors in attempted translation. We recognize the potential for language bias; therefore, the initial search will include articles written in any language to quantify the extent of non-English literature excluded from our analysis.

Study selection

All identified records will be collated and uploaded into DistillerSR (Evidence Partners, Ottawa, Canada) and duplicates will be removed. Two primary reviewers (SS, JG) will independently screen all articles in 3 stages: title screening, abstract screening, and full-text screening. Standardized forms created in DistillerSR will facilitate the screening process. As part of an inclusive strategy, agreement from both primary reviewers will be required for an article to be excluded at the title-screening stage. During the abstract and full-text screening stages, conflicts will be flagged for a third expert reviewer (NK) to resolve. Articles will only be included in our analysis if they meet the following criteria: they relate to the management of obesity, are associated with a full-text article of a primary study (no abstract-only search results, guidelines, opinions, or book chapters), are written in English, published in 2000 or later, and pertain to individuals 18 years or older.

Searches will be limited to the year 2000 or later as many pharmacotherapeutic and surgical treatments for obesity prior to the 2000s are either no longer in use or have drastically limited indications, and this review aims to examine decision-making research in the context of the modern era of obesity management. Furthermore, the modern morbidity and mortality rates for today's surgical procedures are sufficiently low that the decision to proceed with surgery now is a different discussion to what it has been in the past. 37

Articles selected following full-text screening will be retrieved and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). 38 See Appendix II for the screening questions. Reasons for exclusion of full-text papers will be recorded and reported in the final review. The results of the search will be presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. 39

Data extraction

Data will be extracted by 2 independent reviewers (JG, SS) using the questions in Appendix III. Details about the population, the treatment modalities, and context relevant to the review questions will be extracted. Additional data points will include author details, year and type of publication, country of origin, study aims, methodology, and key findings. For publications investigating a decision aid, the type of aid (eg, video, pamphlet, interactive chart) as well as its components will be recorded. Revision of the data extraction tool during the extraction process will be iterative, but prior to beginning the data extraction process, we will conduct a calibration exercise (pilot test), as outlined by Tricco et al. 40 Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, whenever necessary.

Data analysis and presentation

The analysis for this scoping review will predominantly consist of a summative approach for the data extracted from the published literature.

If provided, definitions of decision-making in obesity management settings will be extracted verbatim from identified sources and summarized in tabular format. References cited to support these definitions will also be presented. The actual decisions being examined by each study will be summarized as well.

Regarding decision aids, a tabular format will be used to highlight the types of aids studied and the treatment modalities they address. Regarding SDM, tabular format will be used to summarize the existing research and the individuals involved in the SDM process (eg, patients, clinicians).

Barriers that have been reported as having an impact on decision-making in obesity management research will be summarized with the frequency of selected studies that examine each barrier. If necessary, descriptive qualitative content analysis may be used to code barriers into overall categories to facilitate a useful presentation of the results. The anticipated broad categories may include concerns over financial considerations, outcomes, treatment risks, changes in lifestyle, and necessary time commitment.

To supplement our in-text discussion, overview graphs or diagrams will be used as appropriate to highlight research gaps pertaining to our review questions, in particular gaps in decision-making research regarding specific treatment modalities, health care contexts, and populations.

Author contributions

JG, SS, NK, DS contributed to the writing of the manuscript. SS, JG, NK, DS, RS contributed to the design of the protocol. RS, SS devised the search strategy and conducted the preliminary search. JG, SS, RS created the data extraction tool.

Appendix I: Search strategy

Cinahl complete (ebsco).

Date searched: January 12, 2022

Appendix II: Article screening strategy and questions

Appendix III: Draft data extraction instrument

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A systematic literature review on obesity: Understanding the causes & consequences of obesity and reviewing various machine learning approaches used to predict obesity

Affiliations.

1 Centre for Software Technology and Management, Faculty of Information Science and Technology, Universiti Kebangsaan Malaysia (UKM), Bangi, 43600, Selangor, Malaysia.
2 Centre for Software Technology and Management, Faculty of Information Science and Technology, Universiti Kebangsaan Malaysia (UKM), Bangi, 43600, Selangor, Malaysia. Electronic address: [email protected].
3 RIADI Laboratory, University of Manouba, Manouba, Tunisia; College of Computer Science and Engineering, Taibah University, Medina, Saudi Arabia.
4 Center for Artificial Intelligence Technology, Faculty of Information Science and Technology, Universiti Kebangsaan Malaysia (UKM), Bangi, 43600, Selangor, Malaysia.
PMID: 34426171
DOI: 10.1016/j.compbiomed.2021.104754

Obesity is considered a principal public health concern and ranked as the fifth foremost reason for death globally. Overweight and obesity are one of the main lifestyle illnesses that leads to further health concerns and contributes to numerous chronic diseases, including cancers, diabetes, metabolic syndrome, and cardiovascular diseases. The World Health Organization also predicted that 30% of death in the world will be initiated with lifestyle diseases in 2030 and can be stopped through the suitable identification and addressing of associated risk factors and behavioral involvement policies. Thus, detecting and diagnosing obesity as early as possible is crucial. Therefore, the machine learning approach is a promising solution to early predictions of obesity and the risk of overweight because it can offer quick, immediate, and accurate identification of risk factors and condition likelihoods. The present study conducted a systematic literature review to examine obesity research and machine learning techniques for the prevention and treatment of obesity from 2010 to 2020. Accordingly, 93 papers are identified from the review articles as primary studies from an initial pool of over 700 papers addressing obesity. Consequently, this study initially recognized the significant potential factors that influence and cause adult obesity. Next, the main diseases and health consequences of obesity and overweight are investigated. Ultimately, this study recognized the machine learning methods that can be used for the prediction of obesity. Finally, this study seeks to support decision-makers looking to understand the impact of obesity on health in the general population and identify outcomes that can be used to guide health authorities and public health to further mitigate threats and effectively guide obese people globally.

Keywords: Diseases; Machine learning; Obesity; Overweight; Risk factors.

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Pharmacological support for the treatment of obesity—present and future.

1. Introduction

2. drugs registered for obesity treatment, 2.1. orlistat, 2.2. bupropion with naltrexone, 2.3. phentermine with topiramate, 2.4. lorcaserin, 2.5. liraglutide, 2.6. semaglutide, 3. drugs registered in other disease entities demonstrating a weight-reducing effect, 3.1. exenatide, 3.2. dulaglutide, 3.3. tirzepatide, 3.4. glucose-sodium cotransporter inhibitors (sglt-2i), 4. drugs in clinical trials, 4.1. cotadutide, 4.2. triple glp-1/glucagon/gip receptor agonist, 4.3. setmelanotide, 4.4. tesofensine, 4.5. methylphenidate, 4.6. zonisamide with bupropion, 4.7. cetilistat, 4.8. type 1 cannabinoid receptor antagonist, 4.9. sildenafil, 4.10. oxytocin, 4.11. velneperit, 4.12. amylin analogues, 4.13. peptide tyrosine-tyrosine, 4.14. fibroblast growth factor analogue 21, 4.15. mirabegron, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Study	Study Design	Baseline Sample	Duration	Dose of Bupropion/Naltrexon	Body Mass Reduction (%)	Percent of Patients with 5/10/15% Weight Reduction	Additional Benefits
COR I [ ]	RCT	1742 patients ages 18–65 years with a BMI of 30–45 kg/m and uncomplicated obesity or BMI 27–45 kg/m with dyslipidaemia or AH, or both	56 weeks	360 mg/32 mg 360 mg/16 mg	6.1 5.0	48/25/12 39/20/9	SSR in WC, TG, hs-CRP, FINS, FPG, HOMA-IR, SBP, DBP. SSI in HDL-C. SSR in WC, TG, hsCRP, HOMA-IR, SBP, DBP. SSI in HDL-C.
COR II [ ]	RCT	1496 patients ages 18–65 years with a BMI of 30–45 kg/m , or a BMI of 27–45 kg/m and controlled AH and/or dyslipidemia.	56 weeks	360 mg/32 mg	6.5	50.5/28.3/13.5	SSR in WC, TG, LDL-C, hsCRP, FINS, HOMA-IR, SBP. SSI in HDL-C.
COR-BMOD [ ]	RCT	793 patients ages 18–65 years with a BMI of 30–45 kg/m , or a BMI of 27–45 kg/m in the presence of controlled AH and/or dyslipidemia	56 weeks	360 mg/32 mg	9.3	66.4/41.5/29.1	SSR in WC, TG, FINS, HOMA-IR. SSI in HDL-C.
COR-DM [ ]	RCT	505 patients with T2DM and ages 18–70 years, with a BMI of ≥27 and ≤45 kg/m , HbA1c between 7% and 10%, and FPG <270 mg/dL	56 weeks	360 mg/32 mg	5.0	≥5% weight loss in 44.5% patients	SSR in WC, HbA1c, TG. SSI in HDL-C.

Study	Study Design	Baseline Sample	Duration	Dose of Phentermine/Topiramat	Body Mass Reduction (%)	Percent of Patients with 5/10/15% Weight Reduction	Additional Benefits
EQUIP [ ]	RCT	1267 patients with a BMI of ≥35 kg/m , TG ≤ 200 mg/dL with treatment of 0–1 lipid-lowering medication, BP ≤ 140/90 mmHg with treatment of 0–2 antihypertensive medications, FPG ≤ 110 mg/dL	56 weeks	15 mg/92 mg 3.73 mg/23 mg	10.9 5.1	66.7/47.2/32.3 44.9 /18.8/7.3	SSR in WC, TG, FPG, TCH, LDL-C, SBP, DBP, TCH/HDL-C ratio. SSI in HDL-C. SSR in WC, SBP. SSI in HDL-C.
CONQUER [ ]	RCT	2487 patients aged 18–70 years, with a BMI of 27–45 kg/m , ≥2 comorbidities at baseline (SBP 140–160 mmHg or 130–160 mmHg in T2DM patients, DBP 90–100 mmHg or 85–100 mmHg in T2DM patients or taking ≥2 antihypertensive drugs; TG 2.26–4.52 mmol/L or using ≥2 lipid-lowering drugs; FBG > 5.5 mmol/L or 2 h after OGTT > 7.77 mmol/L or diagnosed T2DM managed with lifestyle changes or metformin monotherapy; WC ≥ 102 cm for men or 88 cm for women.	56-weeks	15 mg /92 mg 7.5 mg/46 mg	9.8 7.8	70/48/- 62/37/-	SSR in WC, SBP, DBO, TCH, LDL-C, TG, FPG, HbA1c, FINS, Homa-IR, hsCRP. SSI in HDL-C, adiponectin. SSR in WC, SBP, TCH, TG, FPG, HbA1c, FINS, HOMA-IR, hsCRP. SSI in HDL-C, adiponectin.
SEQUEL [ ]	RCT	676 patients with a BMI of 27–45 kg/m and two or more comorbidities (AH, dyslipidaemia, diabetes or prediabetes, or abdominal obesity),	56 weeks	15.0 mg/92 mg 7.5/46 mg	10.5 9.3	79.3/53.9/31.9 75.2/50.3/24.2	SSR in TG, LDL-C, FPG, FINS, HbA1c, SBP, DBP. SSI in HDL-C. SSR in TG, LDL-C, FINS, HbA1c, SBP, DBP. SSI in HDL-C.
EQUATE : NCT00563368	RCT	756 patients ages 18–70 years of age who had a BMI of ≥30 and ≤45 kg/m	28 weeks	15 mg/92 mg 7.5 mg/46 mg	9.2 8.5	68/42/- 64/40/-	SSR in WC, SBP, HBA1c. SSR in WC, HbA1c, adiponectin.

Study	Study Design	Baseline Sample	Duration	Dose of Lorcaserine	Body Mass Reduction (%)	Percent of Patients with 5/10/15% Weight Reduction	Additional Benefits
BLOM [ ]	RCT	3182 patients ages 18–65 years and a BMI of 30–45 kg/m or 27–45 kg/m with at least 1 coexisting condition (AH, dyslipidemia, cardiovascular disease, impaired glucose tolerance, or sleep apnea).	52 weeks	10 mg BID	5.81	47.5/22.6	SSR in SBP, DBP, TCH, LFL-C, TG, FPG, FINS, HOMA-IR, hsCRP, fibrinogen.
BLOOSOM [ ]	RCT	4008 patients ages 16–65 years, with a BMI of 30–45 kg/m or 27–29.9 kg/m with obesity-related comorbid condition	52 weeks	10 mg BID 10 mg QD	5.8 4.7	47.2/22.6/- 40.2/17.4/-	SSR in WC, TG, ApoB, total body fat, lean body mass. SSI in HDL-C. SSR in WC, TG/ SSI in HDL-C.
BLOOM-DM [ ]	RCT	604 patients ages 18–65 years with T2DM treated with metformin, a SFU, or both; with HbA1c 7–10%; with a BMI of 27–45 kg/m	52 weeks	10 mg BID 10 mg QD	4.7 5.0	37.5/16.3/- 44.7/18.1/-	SSR in WC, HC, HR, FPG, HbA1c, HOMA-IR. SSI in HDL-C. SSR in HC, HR, apoA1, FPG, FINS.
CAMELLIA -TIMI 61 [ ]	RCT	12,000 patients ages at least 40 years old with a BMI of ≥27 kg/m with either established atherosclerotic cardiovascular disease or multiple cardiovascular risk factors	3.3 years	10 mg BID	4.2	38.7/14.6	SSR in HbA1c, FPG.

Study	Study Design	Baseline Sample	Duration	Dose of Liraglutide (9 mg)	Body Mass Reduction (%)	Percent of Patients with 5/10/15% Weight Reduction	Additional Benefits
SCALE Obesity and Prediabetes [ ]	RCT	3731 patients ages ≥ 18 years with a BMI of ≥30 kg/m or ≥27 kg/m with treated or untreated dyslipidemia or AH, without DM	56 weeks	3.0	8.0	63.2/33.1/14.4	SSR in SBP, DBP, HbA1c, FPG, IR, and beta-cell function. SSI in FINS, C-peptide, HDL-C, PAI-1, adiponectin.
SCALE Diabetes [ ]	RCT	846 patients ages ≥18 years with a BMI of ≥27 kg/m taking 0–3 oral hypoglycemic agents (metformin, thiazolidinedione, sulfonylurea) with stable body weight, and HbA1c 7–10%.	56 weeks	1.8 3.0	4,7 6,0	40.4/15.9/- 54.3/25.2/-	SSR in WC, HbA1c, FPG, PPG, HOMA-B. SSI in glucagon, proinsulin, proinsulin to insulin ratio, hsCRP. SSR in WC, HbA1c, FPG, PPG, HOMA-B, HOMA-IR, SBP, TCH, VLDL, TG. SSI in HDL-C, glucagon, proinsulin, proinsulin to insulin ratio, fibrinogen, PAI-1, hsCRP.
SCALE Maintenance [ ]	RCT	422 patients ages ≥ 18 years with a stable BMI of ≥30 kg/m or ≥27 kg/m with comorbidities of treated or untreated dyslipidemia and/or treated or untreated AH who lost ≥5% of initial weight during a low-calorie diet run-in, without DM	56 weeks	3.0	6.2	50.5/26.1/-	SSR in WC, HbA1c, FPG, FINS, TG, hsCRP, SBP.
SCALE Sleep Apnea [ ]	RCT	359 patients ages 18–64 years with a stable BMI (<5% change during the previous 3 months) and a BMI of ≥30 kg/m with moderate or severe OSA	32 weeks	3.0	5.7%	46.3/23.4/-	SSR in HbA1c, FPG, SBP.

Study	Study Design	Baseline Sample	Duration	Dose of Semaglutide (mg)	Body Mass Reduction (%)	Percent of Patients with 5/10/15% Weight Reduction	Additional Benefits
STEP 1 [ ]	RCT	1961 patients ages ≥ 18 years old with one or more self-reported unsuccessful dietary efforts to lose weight and either a BMI of ≥30 kg/m or ≥27 kg/m with ≥1 treated or untreated weight-related coexisting conditions (i.e., AH, dyslipidemia, OSAS, CVD)	68 weeks	2.4	14.9	86.4/69.1/50.5	SSR in WC, SBP.
STEP 2 [ ]	RCT	1210 patients ages ≥ 18 years old, with at least one reported unsuccessful dietary effort to lose weight, a BMI of ≥27 kg/m , HbA1c 7–10%, T2DM at least 180 days before screening	68 weeks	2.4 1.0	9.6 6.99	68.8/45.6/25.8 57.1/28.7/13.7	SSR in WC, HbA1c, SBP, FSIN, DBP, TCH, VLDL, free fatty acids, TG, CRP. SSI in HDL-C. SSR in HbA1c.
STEP 3 [ ]	RCT	611 patients with ages ≥ 18 years old, reported ≥1 unsuccessful dietary efforts to lose weight and BMI ≥30 kg/m or ≥27 with ≥1 weight-related comorbidity (CVD, dyslipidemia, AH, OSAS	68 weeks	2.4	16	86.6/75.3/55.8	SSR in WC, SBP, DBP, FPG, HbA1c, FSIN, TCH, LDL-CVLDL, free fatty acids, TG, CRP.
STEP 4 [ ]	RCT	902 patients with ages ≥ 18 years old, with ≥1 reported unsuccessful dietary efforts to lose weight and a BMI of ≥30 kg/m or ≥27 with ≥1 weight-related comorbidity (CVD, dyslipidemia, AH, OSAS) without T2DM.	68 weeks	2.4	7.9	88.7/79/63.4	SSR in WC, SBP, HfA1c, FSIN, FPG, TCH, LDL-C, VLDL-C, TG. SSI in
STEP 6 [ ]	RCT	401 patients with ages ≥ 18 years old, with ≥1 reported unsuccessful dietary efforts to lose weight and a BMI of ≥27 kg/m ported ≥2 treated or untreated weight-related comorbidity or ≥35 with ≥1 weight-related comorbidity (dyslipidemia, AH, or, in Japan only, T2DM diagnosis 80 days before screening and HbA1c 7–10%).	68	2.4 1.7	13.2 9.6	83/61/41 72/42/24	SSR in WC, HbA1c, FSIN, SBP, DBP, PAI-1, CRP, TCH, LDL-C, TG FFA. SSRI in WC, HbA1c, FSIN, SBP, DBP, PAI-1, CRP, FFA, TG, TCH, LDL-C.

Drug	Most Common Side Effects	Serious Side Effects	Interaction	Contraindications	Dosage and Route of Administration
Orlistat	Abdominal pain and discomfort, loose stools, liquid stools, push to the stools, rectal pain and discomfort, headache, fatigue, anxiety	Hypoglycemia infections	Cyclosporine, Acarbose, Oral antidiabetic drugs, Fat-soluble vitamins, Amiodarone	Hypersensitivity to orlistat or to any of the excipients, chronic malabsorption syndrome, cholestasis, breast-feeding	3x/day, p.o.
Bupropion /naltrexone	Nausea, constipation, vomiting, dizziness, dry mouth, headache	Affective disorder, suicidal ideation, seizure, cholecystitis, hepatitis, erythema multiforme, Stevens-Johnson syndrome	Active substances metabolized by cytochrome P450 isoenzymes; CYP2D6 isoenzyme substrates; inducers, inhibitors and substrates of the CYP2B6 isoenzyme; organic cation transporter 2 inhibitors	Hypersensitivity to bupropion, naltrexone or to any of the excipients; uncontrolled hypertension; epilepsy or history of seizures; cancer tumor in the central nervous system; the period immediately after abrupt withdrawal from alcohol or benzodiazepines in an addicted person; history of bipolar affective disorder; psychic bulimia or anorexia nervosa; dependence on long-term use of opioids or opiate agonists (e.g., methadone) and the period immediately after abrupt opiate withdrawal in an addicted person; taking monoamine oxidase inhibitors; severe hepatic impairment; end-stage renal failure or severe renal impairment	2x/day, p.o
Phentermine/topiramat	Dry mouth, paresthesia, constipation, memory impairment insomnia, depression, anxiety	Metabolic acidosis, hypokalemia, angle-closure glaucoma, transient blindness, deafness, atrial fibrillation, arrhythmias, deep vein thrombosis, falls	Antiepileptic drugs, Hydrochlorothiazide, Hypericum perforatum, oral contraceptives, metformin, pioglitazone, glibenclamide, digoxin, lithium, risperidone, central nervous system depressants, carbonic anhydrase inhibitors, potassium-sparing diuretics, valproic acid	Hypersensitivity to phentermine, topiramate, or to any of the excipients; pregnancy; breast feeding; treatment with monoamine oxidase inhibitors	2x/day, p.o
Liraglutide	Gastrointestinal symptoms (for example: nausea, vomiting, diarrhea, constipation, dry mouth, dyspepsia), insomnia, headache, hives	Hypoglycemia, inflammation of the pancreas, cholecystitis, cholelithiasis, acute renal failure	Paracetamol, atorvastatin, griseofulvin, digoxin, lisinopril, oral contraceptives	Hypersensitivity to liraglutide or to any of the excipients, medullary thyroid cancer, pregnancy, breast feeding	1x/day, s.c.
Semaglutide	Gastrointestinal symptoms (for example: vomiting, diarrhea, constipation, nausea, abdominal pain, dyspepsia, bouncing), headache, dizziness, tiredness	Cholelithiasis, hypoglycemia	Paracetamol, oral contraceptives	Hypersensitivity to semaglutide or to any of the excipients, medullary thyroid cancer, pregnancy, breast feeding	1x/week, s.c.
Lorcanserin	Nausea, vomiting, constipation, diarrhea, fatigue, upper respiratory tract infection, urinary tract infection, back pain, headache, dizziness, rash, attention and memory deficit, priapism, hyperprolactinemia	Infections, serotonin syndrome, hypoglycemia	Drugs that interfere with serotonin neurotransmission, drugs metabolized by cytochrome P450 2D6	Hypersensitivity to lorcaserin or to any of the excipients, pregnancy, breast feeding	2x/day, p.o.

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Kosmalski, M.; Deska, K.; Bąk, B.; Różycka-Kosmalska, M.; Pietras, T. Pharmacological Support for the Treatment of Obesity—Present and Future. Healthcare 2023 , 11 , 433. https://doi.org/10.3390/healthcare11030433

Kosmalski M, Deska K, Bąk B, Różycka-Kosmalska M, Pietras T. Pharmacological Support for the Treatment of Obesity—Present and Future. Healthcare . 2023; 11(3):433. https://doi.org/10.3390/healthcare11030433

Kosmalski, Marcin, Kacper Deska, Bartłomiej Bąk, Monika Różycka-Kosmalska, and Tadeusz Pietras. 2023. "Pharmacological Support for the Treatment of Obesity—Present and Future" Healthcare 11, no. 3: 433. https://doi.org/10.3390/healthcare11030433

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Treatment of Obesity with Thyroid hormones in Europe. Data from the THESIS* Collaboration

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The use of thyroid hormones (TH) to treat obesity is unsupported by evidence as reflected in international guidelines. We explored views about this practice, and associations with respondent characteristics among European thyroid specialists.

Specialists from 28 countries were invited to a survey via professional organisations. The relevant question was whether “ Thyroid hormones may be indicated in biochemically euthyroid patients with obesity resistant to lifestyle interventions” .

Of 17,232 invitations 5695 responses were received (33% valid response rate; 65% women; 90% endocrinologists). Of these, 290 (5.1%) stated that TH may be indicated as treatment for obesity in euthyroid patients. This view was commoner among non-endocrinologists (8.7% vs. 4.7%, p < 0.01), private practice (6.5% vs. 4.5%, p < 0.01), and varied geographically (Eastern Europe, 7.3%; Southern Europe, 4.8%; Western Europe, 2.7%; and Northern Europe, 2.5%). Respondents from Northern and Western Europe were less likely to use TH than those from Eastern Europe (p < 0.01). Gross national income (GNI) correlated inversely with this view (OR 0.97, CI: 0.96–0.97; p < 0.001). Having national guidelines on hypothyroidism correlated negatively with treating obesity with TH (OR 0.71, CI: 0.55–0.91).

Conclusions

Despite the lack of evidence, and contrary to guidelines’ recommendations, about 5% of respondents stated that TH may be indicated as a treatment for obesity in euthyroid patients resistant to life-style interventions. This opinion was associated with (i) respondent characteristics: being non-endocrinologist, working in private practice, treating a small number of hypothyroid patients annually and (ii) national characteristics: prevalence of obesity, Eastern Europe, low GNI and lack of national hypothyroidism guidelines.

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Use of Thyroid Hormones in Hypothyroid and Euthyroid Patients: A THESIS questionnaire survey of members of the Irish Endocrine Society

Use of thyroid hormones in hypothyroid and euthyroid patients: a 2020 THESIS questionnaire survey of members of the Hellenic Endocrine Society.

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Introduction

Treatment of Hypothyroidism in Europe by Specialists: An International Survey (THESIS) is a large-scale European study aiming to explore views about the use of thyroid hormones (TH) among thyroid specialists in Europe. It was completed in 2021, and twenty countries have already reported their national data [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ].

THESIS has allowed the evaluation of real-life practices by thyroid specialists that include both evidence-based indications for TH use and that of nonconventional use [ 21 , 22 ]. Here we report the aggregate data with respect to the use of TH in obese euthyroid individuals resistant to lifestyle interventions.

The rationale behind using of TH in euthyroid individuals with obesity was based in a few relevant experimental and clinical observations. It is well recognised that TH have important thermogenic effects that promote caloric expenditure [ 23 ]. Hypothyroid patients are prone to weight gain, mostly due to fluid retention, which may decrease following treatment for hypothyroidism [ 24 ]. In addition, body mass index (BMI) and body weight are typically positively associated with serum thyrotropin (TSH) levels [ 24 , 25 ], although this relationship seems to be somewhat modulated by autoimmunity [ 26 , 27 ]. Nevertheless, no study has demonstrated that TH are effective for weight loss in euthyroid individuals with obesity without causing side effects [ 24 , 28 ]. On the contrary, TH induces iatrogenic thyrotoxicosis [ 24 , 28 ] that is associated with increased somatic as well as psychiatric morbidity and excess mortality [ 29 , 30 , 31 , 32 ], and does not improve quality of life [ 33 ].

We aimed to document the respondent characteristics and views of thyroid specialists members of 28 national European Endocrine Societies about the use of TH in euthyroid subjects with obesity resistant to lifestyle intervention.

Material and methods

Guidelines for internet-based electronic surveys (CHERRIES) were followed. The survey recruited thyroid specialists who were members of national endocrine and/or thyroid scientific professional organizations from European countries with more than 4 million citizens. The project was supervised by a Steering Committee (LH, EVN, EP, PP, RA, and RN).

The survey was conducted between 2019 and 2021 and details are reported elsewhere [ 21 , 22 ]. In brief, the anonymous online questionnaire comprised of eight questions about physician characteristics and twenty-three questions about the use of TH in various clinical scenarios. The survey link was distributed through national thyroid or endocrine professional societies. Two national leads of each country and the Steering Committee were responsible for the authenticity of the data received. The relevant question for obesity was whether “ Thyroid hormones may be indicated in biochemically euthyroid patients with obesity resistant to lifestyle interventions”. The questionnaire was developed in English and the survey was translated into the national language at the discretion of the national leads.

After completing the survey, national leads reported if their country had at the time of the survey (i) national guidelines for thyroid disease, including management of hypothyroidism, and (ii) guidelines for the management of obesity. In the absence of national guidelines, national leads were asked whether any specific international guideline was officially recommended by the national society and whether such guidelines support or discourage the use of TH for obesity.

Statistical analyses

Responses that contained complete information about the respondent’s demographics were considered as valid and included in the analysis.

Statistical calculations were performed with R [ 34 ]. Due to the characteristics of the information, the survey data were not weighted. The information referring to qualitative and quantitative variables is presented in frequencies or proportions, and means with standard deviations, respectively. The association between qualitative variables was calculated using chi-square and Cramer’s tests. Linear, logistic and ordinal regression was performed when applicable [ 35 ], with the statistical and ordinal R packages. The statistical significance level was set at 5%. The effect size is independent of the sample size and the p-value, allowing us to rule out statistically significant but practically irrelevant results [ 36 , 37 ]. Therefore, we reported both p-values and effect size measures and were guided by the latter. Cramer’s V measures the effect size and the values were interpreted according to Rea and Parker [ 36 ], namely Cramer’s V values less than 0.1 are interpreted as insignificant, between 0.1 and 0.2 as weak, between 0.2 and 0.4 as moderate, between 0.4 and 0.6 as relatively strong and above 0.6 as a strong association.

Geographic regions were defined according to the United Nations Statistics Division definition (UNSD): Eastern Europe: Belarus, Bulgaria, Czech Republic, Hungary, Poland, Romania, Russian Federation, Slovakia, Ukraine; Northern Europe: Denmark, Finland, Ireland, Sweden, United Kingdom; Southern Europe: Croatia, Greece, Italy, Portugal, Serbia, Slovenia, Spain; Western Europe: Austria, Belgium, France, Germany, Netherlands, Switzerland; Western Asia: Israel, Turkey. Data on Gross national income (GNI) per capita in US dollars were derived from the World Bank [ 38 , 39 ]. Information about the prevalence of obesity in Europe was derived from the Global Health Observatory data repository of the World Health Organisation (WHO) [ 40 ].

Baseline characteristics of all respondents

Out of 17,232 invitations 5695 valid responses were received (response rate 33.0%). The characteristics of respondents have been described in detail elsewhere [ 21 , 22 ] and are summarised in Table 1 . Notably, the mean age was 49.0 ± 12.0 years; 65.0% (3700/5695) were females; the majority were endocrinologists (90.1%, 5132/5695); 83.1% (4732/5695) treated more than 50 hypothyroid patients per year and 78.8% (4487/5693) had more than 10 years in medical practice.

Baseline characteristics of respondents considering TH for obese patients

Of all 5695 respondents, 290 (5.1%) stated that use of TH may be indicated as a treatment for obesity resistant to life-style intervention (Table 1 ).

Eighty-three percent (241/290) of those who thought obesity was a potential indication for TH were endocrinologists, while the rest were divided between internal medicine, paediatrics, nuclear medicine, surgery, gynaecology, general practice and others. Nevertheless, the view that TH may be indicated for obesity was more common among non-endocrinologists than endocrinologists (8.7% vs. 4.7%, p < 0.01, Cramer’s V 0.054, 95% CI: 0.032–0.081).

On average, these 290 specialists had been practicing medicine for 23.4 (± 11.8) years. Thirty-four percent (99/290) practiced in academic centres, while more than a third (36.9%, 107/290) stated that they also practiced privately.

Demographics

Age and sex of respondents as well as years in professional practice were not associated with the use of TH in euthyroid obese patients. However, volume of thyroid disease management did impact: thyroid specialists who treated more hypothyroid patients per year were less likely to consider TH for obese patients than those who treated fewer patients with hypothyroidism (p < 0.01). Respondents working in private practice considered obesity as a potential indication for TH more frequently than those in the public sector (6.7% vs. 4.5%; p < 0.01, Cramer’s V 0.046, 95% CI: 0.024–0.073), while no association was found with working in an academic or non-academic environment (4.5% vs. 5.4%; p = 0.13). Being member of an international Thyroid Society increases the chance of using TH to treat obesity, but Cramer’s was very low (data not shown) (Table 1 ).

National and regional variations

There were marked national and regional variations in respondents’ views on obesity as an indication for TH use. The highest attitude to this use were from Serbia (21.2%) and Bulgaria (14.2%), and the lowest from Portugal (1.8%), France and Italy (both 1.7%), Switzerland (1.1%) and Ireland (0%) (Table 2 ). There were significant differences between Eastern and Western European respondents (7.3% vs. 2.7%, respectively, p < 0.01). The other three regions showed intermediate responses. In general, respondents from Northern and Western Europe were less likely to regard obesity as an indication for TH use than those from Eastern Europe (p < 0.01, Cramer’s V 0.076 95% CI: 0.053–0.103) (Fig. 1 ).

Physicians’ use of thyroid hormone (TH) for obesity and prevalence of obesity in countries included in the study. The line represents predicted probabilities obtained by univariable logistic regression (OR 1.09, 95%, CI 1.05–1.13 per 1 kg/m 2 , p < 0.001). Please note that the line is slightly curved. Using a linear regression plot is not suitable as we analysed the binomial (Yes–No) variable and the probability of obtaining “Yes” for different levels of obesity

Prevalence of obesity

The view that TH treatment may be indicated in obese euthyroid patients was positively associated with published data on the prevalence of obesity in different countries (OR 1.09, CI: 1.05 to 1.13; p < 0.001) [ 41 ] (Figs. 1 and 2 ).

Source WHO [Ref 41]. B Percentage of specialists who manage obesity with thyroid hormones in Europe according to the THESIS survey (data in Table 2 ). C Gross national income per capita in the countries included in the THESIS survey. Source the World Bank [Ref 40]

Geographical inequalities in the A Prevalence of obesity in Europe by country.

Gross national income and use of TH in obesity

The propensity to express the view that TH may be indicated in obesity correlated with decreasing GNI (OR 0.969, CI: 0.961–0.977; p < 0.001, per 1000 US$). Interestingly, regardless of the medical practices found in the present investigation, we observed that the prevalence of obesity was inversely correlated with the GNI (Figs. 3 and 4 ).

Physicians’ use of thyroid hormone (TH) for obesity and Gross national income (GNI) in countries included in the study. The line represents predicted probabilities obtained by univariable logistic regression (OR 0.97, 95% CI 0.96–0.98 per 1000 US $, p < 0.001). Please note that the line is curved. Using a linear regression plot is not suitable as we analysed the binomial (Yes–No) variable and the probability of obtaining “Yes” for different levels of GNI

Obesity prevalence and Gross national income (GNI) in countries included in the study. It’s worth noting that in this case, a linear regression is appropriate as we correlated Obesity and GNI per country. The choice of regression method was based on the nature of the variables and the research question we were trying to answer

National guidelines and use of TH in obesity

Of the 28 participating countries, 22 provided information on the existence of national guidelines for thyroid disease and obesity. Additional information relating to four countries was obtained from websites of national professional organisations. Information about Ukraine and Belarus could not be obtained. Countries lacking national guidelines for thyroid disease mostly followed the two major international guidelines (European Thyroid Association and American Thyroid Association).

Twenty of the 28 countries represented in THESIS had national guidelines for obesity, and 13 for hypothyroidism. None of the published guidelines (either national or international) on thyroid disease and obesity recommend treating obesity with TH (Table S1 , supplementary material). The availability of nationally endorsed obesity guidelines did not influence views on the use of TH for obesity in either univariate or multivariate models. However, the presence of thyroid guidelines was associated with unfavourable views on use of TH for obesity (univariate OR 0.68, 95%, CI 0.53–0.88, p = 0.002; multivariate OR 0.71, 95%, CI 0.55–0.91, p = 0.008). (Tables S1 and S2).

In this study we found that around 5% of European thyroid specialists still consider obesity as a potential indication for TH use. This figure is small and reflects that most specialists follow the indications of TH treatment based on evidence, as no national or international guidelines on obesity or hypothyroidism endorse the use of TH for euthyroid obese patients (Table S1 ). The universal recommendation against the use of TH in obesity in this scenario is based on the absence of evidence of favourable outcomes and the potential for causing more harm than benefit [ 42 ]. Therefore, it is alarming that use of TH for obesity reached up to 14 to 21% in some European countries, such as Bulgaria and Serbia. Given the high prevalence of obesity in Europe, the inappropriate use of TH could potentially harm significant number of euthyroid obese patients. Previous studies have shown that even in hypothyroid patients, there is a high risk of overtreatment leading to increase cardiovascular disease and mortality [ 43 ], so one could speculate that treating euthyroid patients with TH is likely to lead to overtreatment.

Our findings are novel in that the tendency to treat euthyroid obese patients with TH was associated with respondent characteristics (non-endocrinologists, working in private practice, treating a small number of hypothyroid patients per annum, practicing in a non-academic environment), and broader national and regional characteristics (prevalence of obesity, Eastern Europe, low GNI, absence of endorsement of thyroid guidelines by national professional societies).

It is interesting to note that specialist views on the use of TH treatment for obesity correlated positively with the national prevalence of obesity. In addition, although speculative, it is possible that an easier access to expensive anti-obesity therapies could impact on the differences noted between treatments in countries with different GNI [ 44 ]. In our analysis, GNI correlated inversely with views favouring TH treatment in obese patients. It is well established, that obesity is more prevalent in low income populations, especially in Western countries [ 45 ]. This is probably due to easy access to lower-priced, high-calorie food in these societies. At a national level, the prevalence of obesity decreases as the GNI rises [ 44 ]. Information on the relationship between hypothyroidism and GNI is scarce. A recent Spanish cross-sectional study found that low-income or unemployed people have a higher frequency of hypothyroidism and hyperthyroidism than more privileged socioeconomic groups [ 46 ]. Potential explanations, although cause-effect relationship is difficult to prove, include the bi-directional association between thyroid dysfunction and excess morbidity, whether somatic [ 47 ] or psychiatric [ 48 ], leading to reduced physical activity. But also the higher unemployment rate [ 49 ] and the lower income and thereby impaired access to healthier and more expensive food might play a role.

We found significant geographic differences. Respondents from Northern and Western European countries were clearly less prone to consider TH in obesity than respondents from other countries. In Southern European countries, however, the percentage of respondents who considered TH treatment in obesity rose from 2.5–2.7% to 4.8% compared to Northern and Western Europe. Within Southern Europe, two distinct groups of countries can be identified. Percentages of proponents of TH for obesity in Italy, Portugal, and Spain were very similar to those found in Northern and Western Europe, while values were much higher in Croatia, Greece and Serbia (8.5, 9.5 and 21.2% respectively). Multivariate analysis showed that using TH to treat obesity is associated with geographic region, practicing in private clinic and obesity prevalence in the area. There was no relation between male to female respondents’ ratio and use of TH to treat obesity.

Plausible explanations for the use of TH in obesity

While it is correct to assume that hypothyroidism is associated with weight gain, decreased thermogenesis and metabolic rate [ 50 ], it does not directly follow that the reverse is true. Obesity is usually not associated with hypothyroidism [ 51 ]. However, blood TSH levels increase in parallel with increasing BMI in the euthyroid population, and levothyroxine requirement increases in obese hypothyroid patients [ 25 , 27 ]. The mechanism behind this increase in TSH in obese populations is poorly understood, but it seems to be a consequence rather than the cause of obesity and reverses with restoration of normal BMI through lifestyle changes [ 52 ]. It has been speculated that it probably represents a process of adaptation to nutritional status or an alteration of thyroid structure; actually a differential gene expression profiling of metabolic and immune pathways in thyroid tissues of patients with obesity has been observed [ 53 ]. However, the relationship between serum TH and obesity is not a constant finding: an observational study in a cohort of more than 400 euthyroid individuals could not confirm this association between serum TH levels and obesity [ 54 ].

Despite the absence of a rational scientific basis, TH have been used in the past in attempts to induce weight loss in obese euthyroid subjects [ 27 ]. This practice has two major drawbacks. TH supplementation generally does not result in weight loss [ 55 ] and can induce iatrogenic thyrotoxicosis in these individuals, which is associated with adverse health outcomes such as increased risk of fracture [ 56 ] and excess cardiovascular risk [ 43 ]. Therefore, TH therapy should be discouraged in euthyroid patients [ 57 ].

The characteristics associated with those respondents recommending TH for euthyroid obese individuals is novel and intriguing. Shortfalls in fulfilment of educational needs, inexperience, professional antagonism, low salaries for medical practitioners and lack of guidance by professional organisations in some countries are some of the physician-related factors that may be relevant. Undoubtedly, patient expectations and pressure on physicians may also play a role.

Acknowledgements

The authors wish to thank all national endocrine and thyroid professional organisations and their members who responded to the THESIS questionnaire.

Open Access funding provided thanks to the CRUE-CSIC agreement with Springer Nature.

Author information

THESIS: T reatment of H ypothyroidism in E urope by S pecialists: An I nternational S urvey.

Authors and Affiliations

Department of Endocrinology and Nutrition, Clínica Universidad de Navarra, Pío XII, 36., 31080, Pamplona, Spain

J. C. Galofré

Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain

Thyroid Task Force From the Sociedad Española de Endocrinología y Nutrición (SEEN), Madrid, Spain

J. C. Galofré & J. J. Díez

Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain

Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Majadahonda, Madrid, Spain

Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain

Scientific Committee Associazione Medici Endocrinologi, Milan, Italy

R. Attanasio

Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

E. V. Nagy, E. Berta & M. Bodor

Division of Endocrinology, V. Fazzi Hospital, Lecce, Italy

Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy

Institute of Translational and Clinical Research, Newcastle University, Newcastle Upon Tyne, UK

Faculty of Medicine, University of Belgrade, Belgrade, Serbia

M. Žarković & B. N. Beleslin

Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey

Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, School of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece

M. Alevizaki

Department of Endocrinology and Metabolism, Koru Ankara Hospital, Kizilirmak, Ankara, Turkey

Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland

T. Bednarczuk

Institute of Endocrinology, Diabetes and Metabolic Disorders, Univeristy Clinical Center of Serbia, Belgrade, Serbia

B. N. Beleslin

Clinic of Endocrinology and Metabolism, Medical Faculty, University Hospital “Sofiamed”, Sofia University “Saint Kliment Ohridski”, Sofia, Bulgaria

A. M. Borissova

Clinic of Endocrinology and Metabolism, University Hospital “Alexandrovska”, Sofia, Bulgaria

Department of Internal Medicine, Medical University Sofia, Sofia, Bulgaria

Thyroid Disease and Endocrine Tumor Department, Sorbonne Universitè, Hôpital Pitié-Salpêtriére, Paris, France

C. Buffet & L. Leenhardt

Department of Endocrinology Diabetology and Nutrition, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium

M. C. Burlacu

Thyroid and Osteoporosis Praxis, Kumberg, Austria

Thyroid Practice for Radiofrequency Ablation, Vienna, Austria

Department of Endocrinology No. 1, N.V. Sklifosovsky Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation

V. Fadeyev & T. Morgunova

Section of Clinical Medicine, Faculty of Health & Medical Sciences, University of Surrey, Guildford, Surrey, UK

B. C. T. Field

Department of Endocrinology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands

Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, University-Duisburg-Essen, Essen, Germany

Department of Surgery, Tampere University Hospital, Tampere, Finland

3rd Department of Medicine, 1st Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic

J. Jiskra & M. Kršek

Division of Endocrinology, Diabetes and Metabolism, University of Lausanne, Lausanne, Switzerland

Internal Medicine III, Division of Endocrinology and Metabolism, Medical University of Vienna, Vienna, Austria

5th Department of Internal Medicine, Medical Faculty of Comenius, University and University Hospital, Bratislava, Slovakia

Department of Endocrinology, Skåne University Hospital, Malmö, Sweden

M. Lantz & T. Planck

1st Department of Internal Medicine of the Medical Faculty, P.J. Šafárik University Košice, Košice, Slovakia

I. Lazúrová

Department of Reproductive Endocrinology, Institute of Endocrinology and Metabolism Named after V.P. Komissarenko, National Academy of Medical Science of Ukraine, Kyiv, Ukraine

V. Luchytskiy

Endocrinology, Diabetes and Metabolism Service, Centro Hospitalar Universitário de Santo António, Porto, Portugal

Robert Graves Institute, Tallaght University Hospital, Dublin, Ireland

Department of Endocrinology, Tampere University Hospital, Tampere, Finland

Diabetes & Endocrinology Section, Beacon Hospital, Beacon Court, Dublin, Ireland

School of Medicine, University College Dublin, Dublin, Ireland

Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania

D. A. Niculescu & C. Poiana

Department of Endocrinology, Diabetes and Metabolic Diseases “Mladen Sekso”, University Hospital Center “Sisters of Mercy”, Zagreb, Croatia

Thyroid Cancer Service, Endocrinology and Metabolism Institute, Beilinson Hospital and Davidoff Cancer Center, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Petah Tikva, Israel

E. Robenshtok

Cabinet Médical 2, Rue Bellefontaine, Lausanne, Switzerland

P. O. Rosselet

Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznań, Poland

Department of Endocrinology, Odense University Hospital, Odense, Denmark

K. R. Riis & L. Hegedüs

Department of Endocrinology, Belarusian State Medical University, Minsk, Republic of Belarus

A. Shepelkevich

V.P. Komisarenko Institute of Endocrinology and Metabolism of Academy of Medical Sciences of Ukraine, Kyiv, Ukraine

Department of Internal Medicine, Endocrine Unit, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium

Department of Medicine I, Klinikum Vest GmbH, Knappschaftskrankenhaus Recklinghausen, Academic Teaching Hospital, Ruhr-University Bochum, Recklinghausen, Germany

I. Vardarli

5th Medical Department, Division of Endocrinology and Diabetes, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany

Rotterdam Thyroid Center, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands

W. E. Visser

Department of Endocrinology and Diabetes Centre, Hellenic Red Cross Hospital, Athens, Greece

M. Vryonidou

East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, Surrey, UK

Y. R. Younes

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Conceptualization, LH, PP, EP, and EVN; Analysis, LH, PP, EP, EVN, RA, RN, JCG, JJD and MZ; Methodology, LH, PP, EP, EVN, RA, RN and MZ; Supervision, LH, PP, EP, EVN, RA, RN and MZ; Writing the original draft, JCG and JJD; Writing-review and editing, all authors. All authors have read and agreed to the published version of the manuscript.

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Galofré, J.C., Díez, J.J., Attanasio, R. et al. Treatment of Obesity with Thyroid hormones in Europe. Data from the THESIS* Collaboration. J Endocrinol Invest (2024). https://doi.org/10.1007/s40618-024-02409-z

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Lay summary, introduction, conclusions, acknowledgements, ethical approval, conflict of interest, data availability.

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Doctors and patients’ perspectives on obesity. A Q-methodology study

Both authors contributed equally to the study.

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Qays Shahed, Karolina Baranowska, Marije C Galavazi, Yang Cao, Michiel A van Nieuwenhoven, Doctors and patients’ perspectives on obesity. A Q-methodology study, Family Practice , Volume 39, Issue 4, August 2022, Pages 694–700, https://doi.org/10.1093/fampra/cmab169

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Obesity is associated with stigma and discrimination. Health care providers should approach these patients professionally and without stigma, since treatment of obesity requires a relationship with mutual understanding between the doctor and patient.

To explore how patients and general practitioners (GPs) perceive obesity, using Q-methodology, which allows quantitative analysis of qualitative data.

A Q-methodology study, comprising 24 patients with obesity and 24 GPs. We created 48 statements with viewpoints on obesity. All participants sorted these statements in a forced grid with a quasi-normal distribution ranking from −5 (most disagree) to +5 (most agree). Subsequently, factor analysis was performed. Six patients were interviewed to explain their viewpoints.

Analysis yielded 3 dominant groups (factors) of patients: (i) They acknowledge the importance of healthy lifestyle and feel mistreated by health care. (ii) They have a decreased quality of life, but do not blame health care, and (iii) They don’t need treatment and don’t have an impaired quality of life. For the GPs, the 3 dominant factors were: (i) They have understanding for the patients and feel that health care is insufficient, (ii) They believe that obesity may be hereditary but mainly is a lifestyle problem, and (iii) They believe obesity can be treated but is very difficult.

Viewpoints on obesity were different, both within and between the groups. Some GPs consider obesity mainly as a lifestyle problem, rather than a chronic disease. If patients and doctors can find mutual viewpoints on obesity, both patient satisfaction and a treatment strategy will be more effective.

Obesity affects quality of life and increases the risk of diseases such as type 2 diabetes, fatty liver disease, cardiovascular disease, and cancer. Achieving and maintaining weight loss is difficult and for this reason a mutual understanding between the general practitioner (GP) and the patient is crucial. We used Q-methodology to study the patients and GPs perspectives on obesity. We show that there are different groups of patients that have different perspectives on obesity, but also different groups of doctors who have different perspectives on obesity. If the GP is aware of the fact that the patients’ viewpoints regarding obesity may be different than his/her own viewpoints, it allows improvement of the doctor–patient communication and hence, patient satisfaction.

Viewpoints on obesity differ, both within and between patients and GPs.

Different subgroups of viewpoints on obesity can be identified with Q-methodology.

Some GPs consider obesity a lifestyle problem, rather than a chronic disease.

Q-method is suitable for investigating subjective experiences and perspectives.

The misconception that obesity is a lifestyle choice, that can be reversed simply by exercising willpower, has become cemented in the minds of the general public and much of the medical profession. However, obesity has now been acknowledged by the European Commission as a disease in its own right. 1 The obesity pandemic is getting worse in both adults and children and adolescents. 2 In Sweden, 15% of women and 16% of men suffer from obesity. 3 It is a complex chronic metabolic disease with a multifactorial pathogenesis, 4 associated with type 2 diabetes mellitus, nonalcoholic fatty liver disease, cardiovascular diseases, and different types of cancer. 5 In addition, obesity has consequences for mental health as a result of weight stigma and discrimination, and may lead to social isolation. 6 Current treatments for obesity comprise lifestyle changes including diet and exercise, drugs, psychotherapy, and bariatric surgery. 7

The general practitioner (GP) is often the first doctor who meets the patient with obesity-related problems. However, as mentioned above, many GPs do not consider obesity as a serious medical condition that requires treatment, 8 but rather as a lifestyle problem. This discrepancy has a negative impact on the relationship between doctors and patients. In addition, there is scepticism regarding the treatment options for obesity, but GPs still recommended them in order to maintain a good relationship with the patient. 9 Previous research demonstrates the importance of good communication between GPs and patients to increase the probability that an intervention will become successful. 10

One method to study people’s perspectives on a certain topic is via Q-methodology, which is a combined qualitative and quantitative method for investigating subjectivity. 11 , 12 This method is well-established in the social sciences, but remains a relatively novel approach in the medical sciences. It provides a systematic procedure for examining the subjective components of human behaviour, where all the viewpoints of the subjects are clustered into different groups, called factors. 11

Firstly, the researcher gathers all kinds of opinions, beliefs, and information about a topic from different sources, such as previous research and interviews 13 and creates statements about the topic. This is followed by an evaluation of the statements, performed by a group of experts within the topic, to increase the value and content, but also to minimize researcher bias. This evaluation leads to the creation of a so-called Q-set; the final set of statements that will be used. Secondly, the study population is selected, and the viewpoints of the participants should match the research question. 14 Subsequently, the participants rank the statements from their individual perspective using a grid with a quasi-normal, forced distribution (see Fig. 1 ). The grid has the same number of cells as there are statements and has a rating scale from −5 to +5 which represents “most disagree” to “most agree.” All statements must be placed in the grid. 11 In addition, qualitative information can be collected by interviewing participants about their most extreme rankings. When the ranking is completed, all responses are reduced to a few different factors. 14 Each factor represents a distinct group of participants who share similar views. 12 The number of extracted factors is usually between 3 and 6. 14 Thereafter, a factor rotation is performed to make the factors more explainable. Each factor provides information that defines that factor. 11

Score grid for Q-sorting.

The aim of our study was to analyse both the patients and the GPs perceptions about obesity using Q-methodology, and to compare them with each other.

Setting and data sources

We searched for opinions and viewpoints on obesity in different articles and in forums. This led to 52 statements. An expert group from the Obesity Unit (consisting of a doctor, a nurse, a dietician, a psychologist, and a physiotherapist) evaluated these statements and selected a Q-set comprising 48 statements. We transferred the Q-set to www.qmethodsoftware.com , and evaluated the statements to confirm that the language was understandable and that the Q-set could be distributed within the forced-choice grid without conflicts.

Twenty-four doctors, all GPs or GP residents (16 men and 8 women), and 24 patients with obesity (21 women and 3 men) were included. The number of participants is based on the convention that 1 needs roughly half as many participants as there are statements. Patients with obesity were recruited face to face via the obesity unit of the University hospital in Örebro. The participating GPs were recruited during a local primary health care conference. The inclusion criteria for the patients were: (i) body mass index >30 kg/m 2 and (ii) that they had not started with a weight-loss program provided by the Obesity Unit, since we did not want them to be influenced by the information that they would receive during this program. All participants were informed about the purpose and procedure of the study and signed an informed consent. There was no dropping-out. For the patients, the Q-methodology data were collected at the Obesity Unit, Örebro University Hospital. For the GPs, the Q-methodology data were collected at their workplace. No other individuals were present during the data collection. One member of the research team (KB, female, medical doctor) also consecutively interviewed 6 patients to obtain qualitative information about their most extreme rankings, and field notes were made. No standard questionnaire was used for the interviews. The transcripts were not returned to the patients but were verified directly on the spot. Each interview took approximately 30 min. There was no earlier relationship between the participants and the research group. The research group was not biased in any way with respect to viewpoints regarding obesity.

Data analysis

Two members from the research team (QS and KB) imported the anonymized results in PQMethod software. 8 The first step in the analysis was data reduction to summarize factors based on principal component analysis (PCA). The factors were extracted from both the patient and the GP group. We calculated the Z -scores, based on the factor scores from the PCA for every statement, which represented how much each factor agreed or disagreed on every statement. 12 A Pearson’s correlation analysis was performed (SPSS Statistics version 25, IBM Corp, Armonk, NY) to compare the 2 groups, using the Z -scores from every statement from the patient and GP factors.

We extracted 3 different factors from each group. Each factor represented a general viewpoint and was named after their distinguishing statements, as shown in Tables 1 and 2 . Correlations between Z -scores for each statement between all factors are presented in Table 3 .

Distinguishing statements for the patient factors and their rank scores.

Factor .	Statement .	Factor 1 .	Factor 2 .	Factor 3 .
Patient factor 1	41. Health care providers treat patients with obesity worse than those without		−1	1
	7. Individuals with obesity have knowledge about healthy food		−1	0
	9. Individuals with obesity understand the importance of eating healthy		0	0
	43. Individuals with obesity have an impaired quality of life		4	−2
	17. Regular meals protect against obesity		1	2
	19. At least 30 min physical activity per day protects against weight gain		2	2
	1. Obesity can be prevented		2	5
	15. By reducing energy-rich food, weight loss will occur		1	2
	8. Individuals with obesity have healthy food habits		−5	1
	13. Obesity is more common among people with higher education and income		−3	−5
	48. Individuals with obesity who increase their physical activity lose weight		3	1
Patient factor 2	43. Individuals with obesity have an impaired quality of life	1		−2
	28. Early childhood is the time when food- and exercise habits are established	0		0
	30. If you have parents who have obesity, you will develop obesity yourself	−1		−2
	47. Individuals with obesity receive enough support from healthcare	−4		−3
	44. Use of certain drugs leads to obesity	2		4
	36. Individuals with obesity have knowledge about the risks with obesity	3		3
	40. Doctors have too little knowledge about obesity	3		2
	41. Health care providers treat patients with obesity worse than those without	5		1
	24. Alcohol consumption does not increase the risk of weight gain	−1		0
	46. Weight loss does not provide increased quality of life	0		1
	8. Individuals with obesity have healthy food habits	−1		1
Patient factor 3	21. Physical activity improves health regardless of weight	3	2
	5. Obesity is not hereditary	−2	−2
	18. Obesity is often used as an excuse for not exercising	−3	−1
	8. Individuals with obesity have healthy food habits	−1	−5
	41. Health care providers treat patients with obesity worse than those without	5	−1
	3. Obesity is a person’s own choice	−5	−4
	34. Individuals with obesity need treatment	2	3
	37. Individuals with obesity are not interested in their weight	−4	−3
	39. Abuse in childhood increases the risk of obesity	1	1
	43. Individuals with obesity have an impaired quality of life	1	4
	45. Obesity is an eating disorder	1	0
	38. Individuals with obesity often feel bad mentally	4	4
	33. Obesity is a lifelong disease	1	1

Factor .	Statement .	Factor 1 .	Factor 2 .	Factor 3 .
Patient factor 1	41. Health care providers treat patients with obesity worse than those without		−1	1
	7. Individuals with obesity have knowledge about healthy food		−1	0
	9. Individuals with obesity understand the importance of eating healthy		0	0
	43. Individuals with obesity have an impaired quality of life		4	−2
	17. Regular meals protect against obesity		1	2
	19. At least 30 min physical activity per day protects against weight gain		2	2
	1. Obesity can be prevented		2	5
	15. By reducing energy-rich food, weight loss will occur		1	2
	8. Individuals with obesity have healthy food habits		−5	1
	13. Obesity is more common among people with higher education and income		−3	−5
	48. Individuals with obesity who increase their physical activity lose weight		3	1
Patient factor 2	43. Individuals with obesity have an impaired quality of life	1		−2
	28. Early childhood is the time when food- and exercise habits are established	0		0
	30. If you have parents who have obesity, you will develop obesity yourself	−1		−2
	47. Individuals with obesity receive enough support from healthcare	−4		−3
	44. Use of certain drugs leads to obesity	2		4
	36. Individuals with obesity have knowledge about the risks with obesity	3		3
	40. Doctors have too little knowledge about obesity	3		2
	41. Health care providers treat patients with obesity worse than those without	5		1
	24. Alcohol consumption does not increase the risk of weight gain	−1		0
	46. Weight loss does not provide increased quality of life	0		1
	8. Individuals with obesity have healthy food habits	−1		1
Patient factor 3	21. Physical activity improves health regardless of weight	3	2
	5. Obesity is not hereditary	−2	−2
	18. Obesity is often used as an excuse for not exercising	−3	−1
	8. Individuals with obesity have healthy food habits	−1	−5
	41. Health care providers treat patients with obesity worse than those without	5	−1
	3. Obesity is a person’s own choice	−5	−4
	34. Individuals with obesity need treatment	2	3
	37. Individuals with obesity are not interested in their weight	−4	−3
	39. Abuse in childhood increases the risk of obesity	1	1
	43. Individuals with obesity have an impaired quality of life	1	4
	45. Obesity is an eating disorder	1	0
	38. Individuals with obesity often feel bad mentally	4	4
	33. Obesity is a lifelong disease	1	1

Bold value shows the rank score of significant statements for the specified patient factor.

Distinguishing statements for the GP factors and their rank scores.

Factor .	Statement .	Factor 1 .	Factor 2 .	Factor 3 .
GP factor 1	41. Health care providers treats patients with obesity worse than those without weight problem		−3	−2
	9. Individuals with obesity understand the importance of eating healthy		0	0
	40. Doctors have too little knowledge about obesity		−1	−1
	35. There is no effective treatment for obesity		−2	−4
	48. Individuals with obesity who increase their exercise will lose weight		3	0
	37. Individuals with obesity are not interested of their weight		−1	−2
	3. Obesity is a person’s own choice		0	0
GP factor 2	45. Obesity is an eating disorder	−1		−2
	48. Individuals with obesity who increase their exercise will lose weight	−2		0
	23. Smoking increases the risk of weight gain	−1		−3
	25. The public judges individuals with obesity	4		4
	13. Obesity is more common among people with higher education and income	−5		−5
	26. To lose weight is easy	−5		−4
	7. Individuals with obesity have knowledge about healthy food	0		2
	24. Alcohol consumption does not increase the risk of weight gain	−2		−2
	5. Obesity is not hereditary	−2		−3
GP factor 3	11. It is enough to change food habits to lose weight	−1	−3
	46. Weight loss does not provide increased quality of life	−3	−4
	48. Individuals with obesity who increase their exercise will lose weight	−2	3
	17. Regular meals protect against obesity	2	3
	33. Obesity is a lifelong disease	1	2
	6. Individuals with obesity have an unhealthy lifestyle	−2	−1
	32. 5–10% weight loss is not enough to live longer	−3	−1

Factor .	Statement .	Factor 1 .	Factor 2 .	Factor 3 .
GP factor 1	41. Health care providers treats patients with obesity worse than those without weight problem		−3	−2
	9. Individuals with obesity understand the importance of eating healthy		0	0
	40. Doctors have too little knowledge about obesity		−1	−1
	35. There is no effective treatment for obesity		−2	−4
	48. Individuals with obesity who increase their exercise will lose weight		3	0
	37. Individuals with obesity are not interested of their weight		−1	−2
	3. Obesity is a person’s own choice		0	0
GP factor 2	45. Obesity is an eating disorder	−1		−2
	48. Individuals with obesity who increase their exercise will lose weight	−2		0
	23. Smoking increases the risk of weight gain	−1		−3
	25. The public judges individuals with obesity	4		4
	13. Obesity is more common among people with higher education and income	−5		−5
	26. To lose weight is easy	−5		−4
	7. Individuals with obesity have knowledge about healthy food	0		2
	24. Alcohol consumption does not increase the risk of weight gain	−2		−2
	5. Obesity is not hereditary	−2		−3
GP factor 3	11. It is enough to change food habits to lose weight	−1	−3
	46. Weight loss does not provide increased quality of life	−3	−4
	48. Individuals with obesity who increase their exercise will lose weight	−2	3
	17. Regular meals protect against obesity	2	3
	33. Obesity is a lifelong disease	1	2
	6. Individuals with obesity have an unhealthy lifestyle	−2	−1
	32. 5–10% weight loss is not enough to live longer	−3	−1

Correlations between Z -scores for each statement between all factors according to Pearson’s correlation analysis ( P values).

.	Patient factor 1 .	Patient factor 2 .	Patient factor 3 .
GP factor 1	0.808	0.773	0.568
GP factor 2	0.421	0.770	0.262
GP factor 3	0.471	0.792	0.509

.	Patient factor 1 .	Patient factor 2 .	Patient factor 3 .
GP factor 1	0.808	0.773	0.568
GP factor 2	0.421	0.770	0.262
GP factor 3	0.471	0.792	0.509

The table shows that the correlations between the factors varied. Patient factor 1 had the highest correlation ( r = 0.808, P = <0.001) with GP factor 1. However, it has a weak correlation with other GP factors. Patient factor 2 correlated well with all GP factors, meanwhile, patient factor 3 had a moderate correlation with 2 GP factors and the lowest correlation with GP factor 2.

Table 4 shows the statements where the different patients and GP factors agreed and disagreed on most. The extracted factors from the patients explained 62% of the variance of the original Q-sorts and the extracted 3 factors from the GPs also explained 62% of the variance. In factor analysis, this is considered as a valid and acceptable proportion of variance explained by a construct.

Statements where the different patients and GP factors agreed and disagreed on most.

Group and factor number .	Significantly loaded statements .	-Score .
Patients factor 1	25. The public judges individuals with obesity	1.617
	41. Health care providers treat patients with obesity worse than those without	1.516
	27. To keep the weight stable after weight loss is difficult	1.384
	2. Individuals with obesity are lazy	−1.830
	3. Obesity is a person’s own choice	−1.941
	42. Individuals with obesity do not want to lose weight	−2.061
Patients factor 2	27. To keep the weight stable after weight loss is difficult	1.900
	25. The public judges individuals with obesity	1.573
	14. Obesity is a disease with several different causes	1.474
	10. Snacks eating do not lead to obesity	−1.435
	8. Individuals with obesity have healthy food habits	−1.462
	26. To lose weight is easy	−1.960
Patients factor 3	21. Physical activity improves health regardless of weight	1.857
	1. Obesity can be prevented	1.569
	44. Use of certain drugs leads to obesity	1.445
	33. Obesity is a lifelong disease	−1.522
	13. Obesity is more common among people with higher education and income	−1.584
	26. To lose weight is easy	−1.778
GPs factor 1	21. Physical activity improves health, regardless of weight	2.019
	27. To keep the weight stable after weight loss is difficult	1.637
	44. Use of certain drugs leads to obesity	1.360
	42. Individuals with obesity do not want to lose weight	−1.529
	26. To lose weight is easy	−1.627
	13. Obesity is more common among people with higher education and income	−1.807
GPs factor 2	21. Physical activity improves health, regardless of weight	2.079
	14. Obesity is a disease with several different causes	2.052
	28. Early childhood is the time where food- and exercise habits are developed	1.323
	24. Alcohol consumption does not increase the risk of weight gain	−1.688
	5. Obesity is not hereditary	−1.914
	22. Stress does not increase the risk of weight gain	−2.001
GPs factor 3	21. Physical activity improves health, regardless of weight	1.996
	27. To keep the weight stable after weight loss is difficult	1.860
	25. The public judges individuals with obesity	1.594
	26. To lose weight is easy	−1.742
	32. 5–10% weight loss is not enough to live longer	−1.849
	13. Obesity is more common among people with higher education and income	−2.014

Group and factor number .	Significantly loaded statements .	-Score .
Patients factor 1	25. The public judges individuals with obesity	1.617
	41. Health care providers treat patients with obesity worse than those without	1.516
	27. To keep the weight stable after weight loss is difficult	1.384
	2. Individuals with obesity are lazy	−1.830
	3. Obesity is a person’s own choice	−1.941
	42. Individuals with obesity do not want to lose weight	−2.061
Patients factor 2	27. To keep the weight stable after weight loss is difficult	1.900
	25. The public judges individuals with obesity	1.573
	14. Obesity is a disease with several different causes	1.474
	10. Snacks eating do not lead to obesity	−1.435
	8. Individuals with obesity have healthy food habits	−1.462
	26. To lose weight is easy	−1.960
Patients factor 3	21. Physical activity improves health regardless of weight	1.857
	1. Obesity can be prevented	1.569
	44. Use of certain drugs leads to obesity	1.445
	33. Obesity is a lifelong disease	−1.522
	13. Obesity is more common among people with higher education and income	−1.584
	26. To lose weight is easy	−1.778
GPs factor 1	21. Physical activity improves health, regardless of weight	2.019
	27. To keep the weight stable after weight loss is difficult	1.637
	44. Use of certain drugs leads to obesity	1.360
	42. Individuals with obesity do not want to lose weight	−1.529
	26. To lose weight is easy	−1.627
	13. Obesity is more common among people with higher education and income	−1.807
GPs factor 2	21. Physical activity improves health, regardless of weight	2.079
	14. Obesity is a disease with several different causes	2.052
	28. Early childhood is the time where food- and exercise habits are developed	1.323
	24. Alcohol consumption does not increase the risk of weight gain	−1.688
	5. Obesity is not hereditary	−1.914
	22. Stress does not increase the risk of weight gain	−2.001
GPs factor 3	21. Physical activity improves health, regardless of weight	1.996
	27. To keep the weight stable after weight loss is difficult	1.860
	25. The public judges individuals with obesity	1.594
	26. To lose weight is easy	−1.742
	32. 5–10% weight loss is not enough to live longer	−1.849
	13. Obesity is more common among people with higher education and income	−2.014

The table shows the similarities and differences between the patient factors and GP factors. Among the patients, many personal statements were ranked highly. Among the GPs, medical facts about obesity were ranked highly. The majority disagreed with statement 26 and the majority agreed with statement 27. All GP factors and 1 patient factor agreed the most with statement 21, meanwhile 2 patient factors and 1 GP factor ranked statement 25 very highly.

Factor 1 (patients): have knowledge about healthy food- and exercise habits and feel mistreated by health care providers

Nine patients showed knowledge about lifestyle changes that lead to weight loss but they do not have good experiences with these lifestyle changes. In contrast to the other patients’ viewpoints, these patients strongly feel that health care is mistreating them.

One patient said:

I received documentation about a gastric bypass when I sought care for a urinary tract infection. They only think that I have to train more, eat a low-calorie diet or should have a gastric bypass. You do not get help or support for anything else. Factor 2 (patients): suffering from obesity for a long time but do not blame health care providers

Seven patients with obesity highlighted that early childhood is the time when food- and exercise habits are developed and that there is a hereditary component. These patients confirm that obesity affects their quality of life. They believe that doctors have sufficient knowledge about obesity and that they receive support from health care providers. One patient said:

“I have had problems with my weight and hypothyroidism since birth and even though I am told to eat right and despite doing so, you are criticized that you do not. Throughout my whole childhood, I have eaten according to the plate model but I am still not properly treated.”

This patient explained that she felt criticized by her environment and although she felt that she was not treated adequately, she understood how difficult it is to treat obesity.

Factor 3 (patients): do not think that obesity has an impact on the quality of life and do not think they need any help

Five patients believed that obesity does not affect the quality of life and that it is not a hereditary condition. Although they are aware of their condition, they do not think they need treatment, and in contrast to other viewpoints, they do not think that obesity is a lifelong disease. One patient said:

I think obesity depends on many things, both medications but also life situation. I think that if you look backward and look when you became obese, you can relate it to something that happened during that time.

Factor 1 (GP): understand the patients and believe that health care provides insufficient support

Ten doctors believed they have insufficient knowledge about obesity and that health care providers treat the patients with obesity worse than those without obesity. There is a certain understanding for these patients. Distinguishing for this viewpoint is that they are not sure whether there is an effective treatment for obesity.

Factor 2 (GP): believe that obesity is hereditary and an eating disorder

Four doctors believed that obesity is an eating disorder, as well as a hereditary condition. They agreed the least with the statement that people with obesity are negatively judged and disagreed the least with the statement that losing weight is easy.

Factor 3 (GPs): obesity is not a lifelong disease but it is difficult to lose weight

Seven doctors believed that patients with obesity have a healthy lifestyle and that it is sufficient to change food habits to lose weight. However, they do not have an opinion regarding whether weight loss increases the quality of life or whether exercise leads to weight loss. Distinguishing from the other viewpoints, they believe that obesity is not a lifelong disease.

Several studies have shown the importance of good communication between GPs and patients. 10 In our study we focussed on the different perspectives on obesity both within and between GPs and patients. Our findings show some differences and similarities in ranking between the distinguishing statements for the patients and GPs, leading to 6 different factors on obesity. Three factors from patients and 3 factors from GPs were considered important in this study.

Comparison to existing literature

Patient factor 1 underlined their belief of the importance of combining diet and exercise for an effective weight loss 15 even though other studies suggest that also behavioural strategies such as self-monitoring are required for a successful result. 16 Besides that, this group agreed strongly on the statement that health care providers treat patients with obesity worse than those without obesity, which the other groups did not. This patient factor had a high correlation with GP factor 1. The correlation between patient factor 1 and the other GP factors was much lower, which may be explained by the fact that these GPs did not highlight statements that were associated with discrimination and lack of knowledge about obesity. Instead, they highlighted medical facts about obesity, which these patients did not take into consideration.

In patient factor 2, this group seemed to have struggled with obesity for a long time and they were unsure whether health care providers could do more for them. This patient group believed that patients with obesity have unhealthy eating habits, and they were neutral about their knowledge regarding obesity-associated health risks. They confirmed that doctors have adequate knowledge about obesity, and did not feel that they were treated any differently than patients without obesity. This is in line with studies in which patients with obesity reported positive experiences with health care. 17 They also confirmed that obesity has an impact on quality of life, thus confirming previous research regarding the relationship between obesity and a decreased quality of life. 18 This viewpoint had a similar correlation with all the GP viewpoints, which means that they share similar opinions about these statements.

Patient factor 3 differed from the other patient factors and showed a believe that patients with obesity neither need treatment, nor have an impaired quality of life. This shows that there are patients with obesity who are less affected by their condition. These patients strongly disagreed on the statement that patients with obesity suffer from impaired mental health, although previous studies demonstrate that obesity and depression often coexist and are interrelated. 19 , 20 They also disagreed on the statement that obesity is a hereditary condition, and they were neutral about obesity as being a persons’ own choice, as well as that they agreed on that patients with obesity have healthy food habits. These patients neither seemed to feel bad about having obesity, nor did they want any help and nor did they consider obesity as a lifelong disease, which almost all other viewpoints did, except GP factor 3. Patient factor 3 had the lowest correlation with all GP viewpoints, especially with GP factor 2, who strongly agreed on obesity as an eating disorder and strongly agreed on obesity as a hereditary condition. Obviously, this group do not consider obesity as a chronic metabolic disease.

Strengths and limitations

We used a method that is well established in the social sciences, but remains a relatively novel approach in medical sciences. The major strength of this method is that Q-methodology allows statistical interpretation of qualitative data and provides a powerful method to investigate differences and similarities in viewpoints between doctors and patients regarding their condition.

There are some limitations. Selection bias may have been introduced. The GPs who participated may have been more interested in obesity and were motivated to make a change, compared with the GPs that did not choose to participate. Secondly, the participating patients may have had more negative experiences with health care providers and they may experience a more impaired health and participated for this reason.

We showed that viewpoints on obesity are different, both within and between patients and GPs. A patient may have completely different viewpoints regarding his/her condition than the GP. Some GPs show viewpoints that are not supported by the current knowledge, such as considering obesity mainly as a lifestyle problem, rather than a chronic disease. In addition, our findings show that a considerable number of patients feel stigmatized because of their obesity, and experience impaired quality of life. For these reasons, awareness of these differences is relevant for clinical practice; if the GP and the patient are able to find mutual viewpoints about obesity, patient satisfaction will improve and a treatment and/or support strategy will be more effective.

The study was funded by departmental resources.

We thank the professionals at the Obesity Unit at the Örebro University Hospital for their support with the review of the Q-sort statements.

Ethical approval was granted by the Etikprövningsmyndigheten Uppsala (Dnr 2019-04756).

None declared.

The data underlying this article will be shared on reasonable request to the corresponding author.

Burki T. European Commission classifies obesity as a chronic disease [published online ahead of print, 2021 Jun 1]. Lancet Diabetes Endocrinol . 2021 ; 9 ( 7 ): 418 . doi: 10.1016/S2213-8587(21)00145-5

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Author notes

client satisfaction
quality of life

Month:	Total Views:
January 2022	238
February 2022	79
March 2022	62
April 2022	63
May 2022	66
June 2022	58
July 2022	70
August 2022	82
September 2022	96
October 2022	86
November 2022	104
December 2022	64
January 2023	76
February 2023	141
March 2023	147
April 2023	103
May 2023	111
June 2023	89
July 2023	85
August 2023	63
September 2023	84
October 2023	88
November 2023	130
December 2023	92
January 2024	139
February 2024	210
March 2024	115
April 2024	128
May 2024	104
June 2024	117
July 2024	91
August 2024	71
September 2024	42

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Obesity: Only half of...

Obesity: Only half of England has access to comprehensive weight loss services

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Peer review
Elisabeth Mahase

Treatments are being restricted by cash poor local services, with many patients being denied specialist drugs, surgery, and support. Elisabeth Mahase investigates

Access to services across England for obesity treatment is severely restricted, an investigation by The BMJ has found. Patients in nearly half the country cannot get appointments with specialist teams for weight loss support and care, including treatment with drugs such as semaglutide, showed responses to freedom of information requests. And in nearly one in five local health areas patients don’t have access to a bariatric surgery service.

Obesity specialists told The BMJ that services for weight management in England are not given the priority they deserve, often being the first to be cut when budgets are tight. Patients are also often the victims of prejudice among many people, including some health professionals and commissioners, who believe that they are less worthy of care than other patients.

Integrated care boards (ICBs) receive annual funding from NHS England to commission services for their local areas, referred to as integrated care systems (ICSs). 1 The boards then allocate money to the services they deem most important to their local population, meaning that those that the commissioners believe are least important may not receive any funding. 2

ICBs are under huge financial pressure, with some reporting large budget deficits and others cutting services in attempts to save money. 3 4 5 6 Earlier this year the former MP Sarah Wollaston resigned her post as chair of Devon’s ICB after refusing to make further cuts. 7

The BMJ analysed responses from all 42 of England’s ICBs about the weight loss services they commission. The responses showed that just over half of the ICBs (24 of the 42) commission both tier 3 and 4 ( box 1 ) adult weight loss services that cover their entire population and are accepting new referrals.

What do NHS obesity services involve?

Generally, there are four tiers of weight management services in England. 8

Tier 1 —Lifestyle advice provided by GPs and practice nurses. This can include signposting of patients to community services.

Tier 2 —Community based services, often run by local councils, which may offer group classes on lifestyle and diet.

Tier 3 —Usually based in hospitals, these services can also be run in the community or in primary care and involve patients being seen by a multidisciplinary team, including physicians, physiotherapists, dietitians, and mental health specialists. They can provide patients with weight loss drugs such as semaglutide.

Tier 4 —Bariatric surgery and bariatric medicine services that offer surgery, post-surgical and annual follow-ups, and more specialist and intensive weight management programmes than those found in tier 3. Often patients will have to go through a tier 3 service before they can access a tier 4 service.

Just over a third of ICBs (15) reported problems with tier 3 services such as that they were currently closed to new patients (six ICBs), that they only covered part of the ICB’s catchment area (seven), or that the ICB didn’t commission any services at this level (four).

Access to tier 4 services, which provide bariatric surgery, is also restricted in many parts of the country, with seven ICBs not providing a bariatric surgery service to patients in their area.

NHS Bath and North East Somerset, Swindon and Wiltshire ICB told The BMJ that it did not commission bariatric surgery because this “is the responsibility of NHS England as it is a specialised commissioning function.” This hasn’t been the case since 2016. 9 The ICB did not respond to The BMJ’s requests for further comment on this issue.

Although most ICBs said that they did fund bariatric surgery, even if they didn’t have a dedicated service, The BMJ found that the referral criteria were inconsistent. Although some hospitals follow the guidance of the National Institute for Health and Care Excellence (NICE), others have further limited access to surgery by, for example, allowing only patients with a BMI >50 (or >40 and with at least one agreed comorbidity) to be accepted.

NICE guidance states that surgery should be available to suitable patients with a BMI ≥40 or between 35 and 39.9 if they have a significant health condition. 10

Stigma and poor provision

Nicola Heslehurst, professor of maternal and child nutrition at Newcastle University and chair of the UK Association for the Study of Obesity, told The BMJ that the current provision of weight management services “doesn’t in any way meet the need.” Whenever there’s a financial squeeze, obesity services always seem to be at the top of the list of care to be cut, she said. “I think there’s a general misunderstanding, including among health professionals and commissioners, about the causes of obesity and the care requirements of obesity, which is really heavily influenced by that perspective of individual responsibility, that people living with obesity are not quite as deserving as people living with other diseases, tied in with all the stigma around people living with obesity.”

Heslehurst emphasised that “people living with obesity need the evidence based care that people living with other diseases get, without question. It needs to be given that same priority.”

She also warned that without “radical” action to improve access to services and tackle all the drivers of obesity, from deprivation and poverty to food advertising, “we are going to end up with an increasing prevalence of obesity, increasing costs of care of obesity, increasing inequalities, and children being set up for a life course of poor health.”

Last year a report by the think tank the Institute for Government concluded that every UK government since 1992 had failed to tackle growing rates of obesity, despite identifying it as a major problem. 11

John Wilding, professor of medicine and honorary consultant physician at the University of Liverpool, also believes that bias plays a key role in these commissioning decisions. “Obesity services are not deemed a priority,” he told The BMJ . “Research has shown that there is an unconscious bias there. I don’t think commissioners are being deliberately difficult, and I don’t think they’re consciously discriminating, but I think there is an unconscious bias which says, ‘This is mostly their fault, so they should just get on with it, go on a diet and lose weight.’ But we know from genetics and other factors that it’s much more complicated than that.”

Wilding, past president of the World Obesity Federation, has 25 years of experience running a specialist service for severe obesity in Liverpool, which has this year been cut by the city council. 12 He has also carried out consultancy work for drug companies and is a commercial trials investigator for Eli Lilly, Novo Nordisk, and Rhythm Pharmaceuticals.

Bariatric surgery underused

England’s poor provision of weight management services is reflected in the number of bariatric surgeries carried out each year. Around 5000 operations are carried out on the NHS in England every year, far lower than in other high income countries such as France, where around 50 000 bariatric procedures are done annually. 13 14 Between 2017-18 and 2022-23 the number of bariatric procedures conducted in the NHS in England fell from 6500 to 4900. 15

The consultant bariatric surgeon Ahmed Ahmed, secretary of the British Obesity and Metabolic Surgery Society, said England had “one of the lowest rates [of bariatric surgery] in the developed world,” despite a 25% prevalence of obesity in adults.

“Bariatric surgery has a strong evidence base showing sustained weight loss, comorbidity resolution, and improved quality of life in those living with severe and complex obesity,” Ahmed said.

The BMJ previously revealed that around 5000 people a year in England may be going abroad for bariatric surgery every year because they can’t access NHS services. 16 This “medical tourism” is a concern for NHS surgeons who have seen patients needing emergency care because of serious complications arising from treatment abroad.

Ahmed has argued that although it would be “logistically and financially impossible for the NHS to treat all two million eligible patients with bariatric surgery,” and that some patients may not choose to undergo such an operation, a “modest increase” from around 5000 to 20 000 procedures a year could be reasonably achieved. This would equate to surgeons carrying out about three each a week, up from less than one a week currently.

Ahmed pointed out that, in addition to the major benefits to patients, investing in better services would be financially beneficial to the NHS and the wider economy. The government estimated that obesity costs the NHS in England around £6.5bn a year and is the second biggest preventable cause of cancer, after smoking. 17

The high cost of glucagon-like peptide 1 receptor agonists (GLP-1 RAs) such as semaglutide means that bariatric surgery may also remain the most cost effective intervention for at least the next decade, said Wilding. “In the future, if you look 20 years ahead, we might end up with less surgery. But I think for the next 10 to 15 years it’s very likely that we’re going to continue to need to have bariatric surgery, and the provision does need to be expanded,” he said.

He said that a gastric bypass “is the most clinically effective and the most cost effective” treatment, with a cost per quality adjusted life year (QALY) gain of between £2000 and £4000. 18 “For context, the NICE cut-off for cost effectiveness is £20 000 per QALY gained. Now, that’s actually better than a lot of other things that are done. It’s better than implantable defibrillators (cost per QALY around £25 000), and it’s actually close to what you get with a hip replacement (about £7000 to £8000 per QALY),” he explained. “The cost per QALY gain at the moment with the current prices for GLP-1 RAs is probably somewhere between £16 000 and £20 000, so it’s a lot more. And that’s when we are only giving them for two years.”

However, Wilding thinks this could shift in the future. “What we don’t know is what the long term prices of these drugs are going to be, but it’s likely that they will come down. I remember having these discussions when statins came out. At that time statins were £30 to £40 a month, and we were having exactly the same conversation then. And now, of course, they’re £2 a month and are widely prescribed.”

Earlier this year The BMJ revealed that the two year Wegovy pilot scheme, which had promised to improve access to semaglutide in the community outside specialist services, was likely to be scrapped as the new government carried out a review of how best to roll out GLP-1 RAs. 19

When asked about the poor provision of weight management services, a spokesperson for NHS England said that the NHS was “working with the Department of Health to support improvements in the obesity pathway.”

Editor’s note (12 September 2024): We have updated Nicola Heslehurst’s job title.

↵ NHS England. Allocations. https://www.england.nhs.uk/allocations
↵ Staffordshire and Stoke-on-Trent Integrated Care Board. Individual Funding Requests. Jul 2022. https://staffsstoke.icb.nhs.uk/contact-us/individual-funding-requests
↵ Mann S. North East London NHS facing budget deficit of almost £37million. Havering Daily. Apr 2024. https://thehaveringdaily.co.uk/2024/04/17/north-east-london-nhs-facing-budget-deficit-of-almost-37million
↵ Jackson N. Fears over looming £1.9bn deficit in Greater Manchester’s NHS budget. Leigh Journal. Jan 2024. https://www.leighjournal.co.uk/news/24082627.fears-looming-1-9bn-deficit-greater-manchesters-nhs-budget
↵ Hunt D. NHS care board reports almost £150m deficit. BBC. May 2024. https://www.bbc.co.uk/news/articles/c4nn59n4yw4o
↵ Hartley J. Nottinghamshire NHS plans to remove care and transport for some patients to make £61m saving. Nottinghamshire Live. https://www.nottinghampost.com/news/health/nottinghamshire-nhs-plans-remove-care-9392920
↵ Gault B. ICB chair resigns after not wanting to sign off cuts. Healthcare Leader. Jun 2024. https://healthcareleadernews.com/news/icb-chair-resigns-after-not-wanting-to-sign-off-cuts
↵ NHS England. Appendix 7: Guidance for clinical commissioning groups (CCGs)—Surgery for severe and complex obesity (clinical guidance). NHS England. May 2016. https://www.england.nhs.uk/wp-content/uploads/2016/05/appndx-7-obesity-surgery-guid.pdf
↵ NHS England. Commissioning guidance to support devolution to CCGs of adult obesity surgical services in 2016/17. May 2016. https://www.england.nhs.uk/wp-content/uploads/2016/05/devolved-services-ccg-guid-obesity.pdf
↵ NICE. Obesity: identification, assessment and management. Jul 2023. https://www.nice.org.uk/guidance/cg189/chapter/Recommendations
↵ An unprecedented, disastrous move”: why has Liverpool City Council cut its obesity services? The Post. Jan 2024. https://www.livpost.co.uk/p/an-unprecedented-disastrous-move
Lacrosniere SM ,
Welbourn R ,
le Roux CW ,
Owen-Smith A ,
Wordsworth S ,
↵ NHS England. National obesity audit: primary bariatric surgical procedures. https://app.powerbi.com/view?r=eyJrIjoiNzdiMTVjN2ItYTY4Yy00ODcxLTllYWYtZmQ0YTljYTg2NTA5IiwidCI6IjM3YzM1NGIyLTg1YjAtNDdmNS1iMjIyLTA3YjQ4ZDc3NGVlMyJ9
↵ Department of Health and Social Care. Government plans to tackle obesity in England. Jun 2023. https://healthmedia.blog.gov.uk/2023/06/07/government-plans-to-tackle-obesity-in-england
Colquitt JL ,

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FDA Approves First Treatment to Reduce Risk of Serious Heart Problems Specifically in Adults with Obesity or Overweight

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Today, the U.S. Food and Drug Administration approved a new indication for use for Wegovy (semaglutide) injection to reduce the risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease and either obesity or overweight. Wegovy should be used in addition to a reduced calorie diet and increased physical activity. Cardiovascular disease is a group of diseases of the heart and blood vessels.

“Wegovy is now the first weight loss medication to also be approved to help prevent life-threatening cardiovascular events in adults with cardiovascular disease and either obesity or overweight,” said John Sharretts, M.D., director of the Division of Diabetes, Lipid Disorders, and Obesity in the FDA’s Center for Drug Evaluation and Research. “This patient population has a higher risk of cardiovascular death, heart attack and stroke. Providing a treatment option that is proven to lower this cardiovascular risk is a major advance for public health.”

Obesity or overweight affect approximately 70% of American adults. Obesity and overweight are serious health issues that increase the risk for premature death and a variety of health problems, including heart attack and stroke.

Wegovy contains semaglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist. Therefore, Wegovy should not be used in combination with other semaglutide-containing products or other GLP-1 receptor agonists.

Wegovy’s efficacy and safety for this new indication were studied in a multi-national, multi-center, placebo-controlled double-blind trial that randomly assigned over 17,600 participants to receive either Wegovy or placebo. Participants in both groups also received standard-of-care medical treatment (e.g., management of blood pressure and cholesterol) and healthy lifestyle counseling (including diet and physical activity). Wegovy significantly reduced the risk of major adverse cardiovascular events (cardiovascular death, heart attack and stroke), which occurred in 6.5% of participants who received Wegovy compared to 8% of participants who received placebo.

The prescribing information for Wegovy contains a boxed warning to inform health care professionals and patients about the risk of thyroid C-cell tumors. Because of this risk, Wegovy should not be used in patients with a personal or family history of medullary thyroid carcinoma or in patients with a rare condition called Multiple Endocrine Neoplasia syndrome type 2.

Wegovy should not be used in patients with a history of a severe allergic reaction to semaglutide or to any of the other ingredients. Patients should stop Wegovy immediately and seek medical help if a severe allergic reaction is suspected.

Wegovy also contains warnings for inflammation of the pancreas (pancreatitis), gallbladder problems (including gallstones), low blood sugar, acute kidney injury, hypersensitivity reactions, diabetic retinopathy (damage to the eye's retina), increased heart rate and suicidal behavior or thinking. Patients should discuss with their health care provider if they have symptoms of pancreatitis or gallstones. If Wegovy is used with insulin or with a medication that causes insulin secretion, patients should speak to their health care provider about the risk of low blood sugar. Healthcare professionals should monitor patients for kidney disease, diabetic retinopathy and depression or suicidal behaviors or thoughts.

The most common side effects of Wegovy include nausea, diarrhea, vomiting, constipation, abdominal (stomach) pain, headache, fatigue, dyspepsia (indigestion), dizziness, abdominal distension, eructation (belching), hypoglycemia (low blood sugar) in patients with diabetes, flatulence (gas buildup) and gastroesophageal reflux disease (heartburn).

Wegovy received Priority Review designation for this indication.

The FDA granted the approval to Novo Nordisk A/S.

Wegovy is also approved to reduce excess weight and maintain weight reduction long term in certain adults with obesity or overweight and certain children with obesity, for use in addition to a reduced calorie diet and increased physical activity.

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Obesity: causes, consequences, treatments, and challenges

Obesity has become a global epidemic and is one of today’s most public health problems worldwide. Obesity poses a major risk for a variety of serious diseases including diabetes mellitus, non-alcoholic liver disease (NAFLD), cardiovascular disease, hypertension and stroke, and certain forms of cancer ( Bluher, 2019 ).

Obesity is mainly caused by imbalanced energy intake and expenditure due to a sedentary lifestyle coupled with overnutrition. Excess nutrients are stored in adipose tissue (AT) in the form of triglycerides, which will be utilized as nutrients by other tissues through lipolysis under nutrient deficit conditions. There are two major types of AT, white AT (WAT) and brown AT, the latter is a specialized form of fat depot that participates in non-shivering thermogenesis through lipid oxidation-mediated heat generation. While WAT has been historically considered merely an energy reservoir, this fat depot is now well known to function as an endocrine organ that produces and secretes various hormones, cytokines, and metabolites (termed as adipokines) to control systemic energy balance. Studies over the past decade also show that WAT, especially subcutaneous WAT, could undergo ‘beiging’ remodeling in response to environmental or hormonal perturbation. In the first paper of this special issue, Cheong and Xu (2021) systematically review the recent progress on the factors, pathways, and mechanisms that regulate the intercellular and inter-organ crosstalks in the beiging of WAT. A critical but still not fully addressed issue in the adipose research field is the origin of the beige cells. Although beige adipocytes are known to have distinct cellular origins from brown and while adipocytes, it remains unclear on whether the cells are from pre-existing mature white adipocytes through a transdifferentiation process or from de novo differentiation of precursor cells. AT is a heterogeneous tissue composed of not only adipocytes but also nonadipocyte cell populations, including fibroblasts, as well as endothelial, blood, stromal, and adipocyte precursor cells ( Ruan, 2020 ). The authors examined evidence to show that heterogeneity contributes to different browning capacities among fat depots and even within the same depot. The local microenvironment in WAT, which is dynamically and coordinately controlled by inputs from the heterogeneous cell types, plays a critical role in the beige adipogenesis process. The authors also examined key regulators of the AT microenvironment, including vascularization, the sympathetic nerve system, immune cells, peptide hormones, exosomes, and gut microbiota-derived metabolites. Given that increasing beige fat function enhances energy expenditure and consequently reduces body weight gain, identification and characterization of novel regulators and understanding their mechanisms of action in the beiging process has a therapeutic potential to combat obesity and its associated diseases. However, as noticed by the authors, most of the current pre-clinical research on ‘beiging’ are done in rodent models, which may not represent the exact phenomenon in humans ( Cheong and Xu, 2021 ). Thus, further investigations will be needed to translate the findings from bench to clinic.

While both social–environmental factors and genetic preposition have been recognized to play important roles in obesity epidemic, Gao et al. (2021) present evidence showing that epigenetic changes may be a key factor to explain interindividual differences in obesity. The authors examined data on the function of DNA methylation in regulating the expression of key genes involved in metabolism. They also summarize the roles of histone modifications as well as various RNAs such as microRNAs, long noncoding RNAs, and circular RNAs in regulating metabolic gene expression in metabolic organs in response to environmental cues. Lastly, the authors discuss the effect of lifestyle modification and therapeutic agents on epigenetic regulation of energy homeostasis. Understanding the mechanisms by which lifestyles such as diet and exercise modulate the expression and function of epigenetic factors in metabolism should be essential for developing novel strategies for the prevention and treatment of obesity and its associated metabolic diseases.

A major consequence of obesity is type 2 diabetes, a chronic disease that occurs when body cannot use and produce insulin effectively. Diabetes profoundly and adversely affects the vasculature, leading to various cardiovascular-related diseases such as atherosclerosis, arteriosclerotic, and microvascular diseases, which have been recognized as the most common causes of death in people with diabetes ( Cho et al., 2018 ). Love et al. (2021) systematically review the roles and regulation of endothelial insulin resistance in diabetes complications, focusing mainly on vascular dysfunction. The authors review the vasoprotective functions and the mechanisms of action of endothelial insulin and insulin-like growth factor 1 signaling pathways. They also examined the contribution and impart of endothelial insulin resistance to diabetes complications from both biochemical and physiological perspectives and evaluated the beneficial roles of many of the medications currently used for T2D treatment in vascular management, including metformin, thiazolidinediones, glucagon-like receptor agonists, dipeptidyl peptidase-4 inhibitors, sodium-glucose cotransporter inhibitors, as well as exercise. The authors present evidence to suggest that sex differences and racial/ethnic disparities contribute significantly to vascular dysfunction in the setting of diabetes. Lastly, the authors raise a number of very important questions with regard to the role and connection of endothelial insulin resistance to metabolic dysfunction in other major metabolic organs/tissues and suggest several insightful directions in this area for future investigation.

Following on from the theme of obesity-induced metabolic dysfunction, Xia et al. (2021) review the latest progresses on the role of membrane-type I matrix metalloproteinase (MT1-MMP), a zinc-dependent endopeptidase that proteolytically cleaves extracellular matrix components and non-matrix proteins, in lipid metabolism. The authors examined data on the transcriptional and post-translational modification regulation of MT1-MMP gene expression and function. They also present evidence showing that the functions of MT1-MMP in lipid metabolism are cell specific as it may either promote or suppress inflammation and atherosclerosis depending on its presence in distinct cells. MT1-MMP appears to exert a complex role in obesity for that the molecule delays the progression of early obesity but exacerbates obesity at the advanced stage. Because inhibition of MT1-MMP can potentially lower the circulating low-density lipoprotein cholesterol levels and reduce the risk of cancer metastasis and atherosclerosis, the protein has been viewed as a very promising therapeutic target. However, challenges remain in developing MT1-MMP-based therapies due to the tissue-specific roles of MT1-MMP and the lack of specific inhibitors for this molecule. Further investigations are needed to address these questions and to develop MT1-MMP-based therapeutic interventions.

Lastly, Huang et al. (2021) present new findings on a critical role of puromycin-sensitive aminopeptidase (PSA), an integral non-transmembrane enzyme that catalyzes the cleavage of amino acids near the N-terminus of polypeptides, in NAFLD. NAFLD, ranging from simple nonalcoholic fatty liver to the more aggressive subtype nonalcoholic steatohepatitis, has now become the leading chronic liver disease worldwide ( Loomba et al., 2021 ). At present, no effective drugs are available for NAFLD management in the clinic mainly due to the lack of a complete understanding of the mechanisms underlying the disease progress, reinforcing the urgent need to identify and validate novel targets and to elucidate their mechanisms of action in NAFLD development and pathogenesis. Huang et al. (2021) found that PSA expression levels were greatly reduced in the livers of obese mouse models and that the decreased PSA expression correlated with the progression of NAFLD in humans. They also found that PSA levels were negatively correlated with triglyceride accumulation in cultured hepatocytes and in the liver of ob/ob mice. Moreover, PSA suppresses steatosis by promoting lipogenesis and attenuating fatty acid β-oxidation in hepatocytes and protects oxidative stress and lipid overload in the liver by activating the nuclear factor erythroid 2-related factor 2, the master regulator of antioxidant response. These studies identify PSA as a pivotal regulator of hepatic lipid metabolism and suggest that PSA may be a potential biomarker and therapeutic target for treating NAFLD.

In summary, papers in this issue review our current knowledge on the causes, consequences, and interventions of obesity and its associated diseases such as type 2 diabetes, NAFLD, and cardiovascular disease ( Cheong and Xu, 2021 ; Gao et al., 2021 ; Love et al., 2021 ). Potential targets for the treatment of dyslipidemia and NAFLD are also discussed, as exemplified by MT1-MMP and PSA ( Huang et al., 2021 ; Xia et al., 2021 ). It is noted that despite enormous effect, few pharmacological interventions are currently available in the clinic to effectively treat obesity. In addition, while enhancing energy expenditure by browning/beiging of WAT has been demonstrated as a promising alternative approach to alleviate obesity in rodent models, it remains to be determined on whether such WAT reprogramming is effective in combating obesity in humans ( Cheong and Xu, 2021 ). Better understanding the mechanisms by which obesity induces various medical consequences and identification and characterization of novel anti-obesity secreted factors/soluble molecules would be helpful for developing effective therapeutic treatments for obesity and its associated medical complications.

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Obesity treatments being restricted by cash poor local services across England, investigation finds

by British Medical Journal

Patients in nearly half the country can't get appointments with specialist teams for weight-loss support and care, including treatment with drugs such as semaglutide. And in nearly one in five local health areas, patients don't have access to a bariatric surgery service, reports Elisabeth Mahase.

The government estimates that obesity costs the NHS in England around £6.5bn a year and is the second biggest preventable cause of cancer, after smoking.

Yet obesity specialists told The BMJ that services for weight management in England are not given the priority they deserve, often being the first to be cut when budgets are tight. Patients are also often the victims of prejudice among many people, including some health professionals and commissioners, who believe they are less worthy of care than other patients.

The BMJ analyzed responses from all 42 of England's Integrated Care Boards (ICBs)—responsible for planning health services for their local population—about the weight loss services they commission.

These showed that just over half of the ICBs (24 of the 42) commission both tier 3 and 4 adult weight loss services that cover their entire population and are accepting new referrals.

Just over a third of ICBs (15) reported problems with tier 3 services such as that they were currently closed to new patients (six ICBs), that they only covered part of the ICB's catchment area (seven), or that the ICB didn't commission any services at this level (four).

Access to tier 4 services, which provide bariatric surgery , is also restricted in many parts of the country, with seven ICBs not providing a bariatric surgery service to patients in their area.

Nicola Heslehurst, senior lecturer in maternal nutrition at Newcastle University and chair of the UK Association for the Study of Obesity, told The BMJ that the current provision of weight management services "doesn't in any way meet the need" and warned that without "radical" action to improve access to services and address all the drivers of obesity, prevalence, costs, and health inequalities would continue to rise.

England's poor provision of weight management services is also reflected in the low number of bariatric surgeries carried out each year (around 5,000 NHS surgeries compared with 50,000 in France).

Yet consultant bariatric surgeon Ahmed Ahmed, points out that gastric bypass "is the most clinically effective and the most cost effective" treatment.

This is backed up by a cost per quality adjusted life year or QALY (a measure of years lived in good health) gain of between £2,000–£4,000, which is well under the NICE cut-off for good value interventions of £20,000 per QALY gained.

When asked about the poor provision of weight management services, a spokesperson for NHS England said the NHS is "working with the Department of Health to support improvements in the obesity pathway."

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A new threat to Merck’s blockbuster cancer treatment, Moderna’s cutbacks, and obesity drugs for kids

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What’s next for Akeso and Summit Therapeutics after their cancer immunotherapy outperformed Merck’s Keytruda in a large Phase 3 clinical trial? Who’s the iconoclastic outsider behind Summit’s success? Why can’t Moderna turn a profit? And should we be giving weight loss drugs to kids?

We talk about all that and more on this week’s episode of “The Readout LOUD.” STAT reporter Matt Herper joins us to break down all the angles of this week’s tumultuous week in cancer immunotherapy, including his up-close look at Summit co-CEO Bob Duggan. We also discuss the latest news in the life sciences, including Moderna pruning its pipeline and its spending, plus results from a study that tested a GLP-1 drug in children.

For more on the Akeso-Summit study results, go here ; the Duggan profile can be read here ; a story looking at Moderna’s financial and R&D update can be found here ; and here’s more on obesity drugs in kids .

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COMMENTS

Obesity: Treatments, Conceptualizations, and Future Directions for a Growing Problem
The pyramid of interventions for the management of obesity includes dieting, augmented by physical exercise, followed by cognitive behavioral strategies, pharmacology, and then surgery towards the tapered end of the treatment pyramid. 2.1. Dieting. Calorie restriction strategies are one of the most common dietary plans.
Obesity in adults: A clinical practice guideline
Obesity is a prevalent, complex, progressive and relapsing chronic disease, characterized by abnormal or excessive body fat (adiposity), that impairs health. People living with obesity face ...
Obesity in adults: a clinical practice guideline
Obesity is a complex chronic disease in which abnormal or excess body fat (adiposity) impairs health, increases the risk of long-term medical complications and reduces lifespan. 1 Epidemiologic studies define obesity using the body mass index (BMI; weight/height 2), which can stratify obesity-related health risks at the population level.Obesity is operationally defined as a BMI exceeding 30 kg ...
Dietary Management of Obesity: A Review of the Evidence
1. Obesity: Prevalence and Magnitude. The obesity epidemic is one of the most predominant public health challenges of the century and its prevalence continues to rise globally with now more than 500 billion obese individuals around the world [].Being associated with over 60 comorbid conditions and at least 12 different types of cancers, obesity poses significant health and economic burdens on ...
Novel Noninvasive Approaches to the Treatment of Obesity: From
This review will focus on noninvasive approaches for the treatment of obesity, including pharmacotherapy, novel drug delivery systems (DDs), vaccines, modulation of the gut microbiome, and gene therapy but will not discuss invasive modalities, such as bariatric surgery and endoscopic gastrointestinal devices. We searched for relevant original ...
Obesity: causes, consequences, treatments, and challenges
Obesity has become a global epidemic and is one of today's most public health problems worldwide. Obesity poses a major risk for a variety of serious diseases including diabetes mellitus, non-alcoholic liver disease (NAFLD), cardiovascular disease, hypertension and stroke, and certain forms of cancer (Bluher, 2019).Obesity is mainly caused by imbalanced energy intake and expenditure due to a ...
Decision-making in the management of obesity: a
Introduction. Obesity, defined as a body mass index (BMI) greater or equal to 30 kg/m 2, is a chronic disease increasing in prevalence worldwide. 1 There are multiple treatment modalities for managing obesity, including surgery, pharmacological treatments, medical management, as well as behavioral modifications. Each treatment modality varies in efficacy, complications, side effects, long-term ...
Obesity: A Review of Pathogenesis and Management Strategies in Adult
Abstract and Figures. Abstract Obesity is a chronic metabolic disease characterized by an increase of body fat stores. It is a gateway to ill health, and has become one of the leading causes of ...
A systematic literature review on obesity: Understanding the causes
The present study conducted a systematic literature review to examine obesity research and machine learning techniques for the prevention and treatment of obesity from 2010 to 2020. Accordingly, 93 papers are identified from the review articles as primary studies from an initial pool of over 700 papers addressing obesity.
Pharmacological Support for the Treatment of Obesity—Present and Future
Obesity is a growing civilization problem, associated with a number of negative health consequences affecting almost all tissues and organs. Currently, obesity treatment includes lifestyle modifications (including diet and exercise), pharmacologic therapies, and in some clinical situations, bariatric surgery. These treatments seem to be the most effective method supporting the treatment of ...
Understanding the pathophysiologic pathways that underlie obesity and
The treatment of obesity remains challenging for HCPs and requires an understanding of energy homeostasis, which is a more complex process than passive accumulation of excess calories and involves both central and peripheral pathways and their complex interplay. Steady-state body weight is determined by different factors that include genetic ...
A systematic literature review on obesity: Understanding the causes
Some genetic and lifestyle factors affect an individual's likelihood of adult obesity; thus, the significant clusters of obesity observed in specific geographical regions and contexts also signal the impact of socioeconomic and environmental factors in "obesogenic" environments [13].Understanding the causes and determinants of obesity is a critical step toward creating effective policy and ...
Obesity and Overweight: Probing Causes, Consequences, and Novel
In the United States, overweight and obesity are chronic diseases that contribute to excess morbidity and mortality. Despite public health efforts, these disorders are on the rise, and their consequences are burgeoning. 1 The Centers for Disease Control and Prevention report that during 2017 to 2018, the prevalence of obesity in the United States was 42.4%, which was increased from the ...
PDF Qualitative studies of obesity: A review of methodology
cial interaction. Obesity stigma has general consequences in many spheres of life for affected individuals. However, interactions oriented to obesity and therefore emphasiz- ing large body size as a problem, are a context in which stigma will be amplified [16]. This has important, but uncharted, consequences for research about obesity, par-
PDF Obesity as a Disease: The Obesity Society 2018 Position Statement
The Obesity Society (TOS) first published a position statement on obe-sity as a disease in 2008 (1). This statement reflected the thoughtful deliberations and consensus of Society members that was published in the same year (2). In 2016, an updated in-house position paper affirmed the 2008 declaration, stating, "TOS recommits to its position ...
Obesity in Adolescents: Prevention and Treatment to ...
Effective treatment can be measured in various ways, including an improvement in a complication associated with obesity, a reduction in BMI, a reduction in risk factors for future diseases, and a changed weight trajectory for an adolescent. 17 Table 1 displays principles of obesity treatment, starting with the least invasive and extending to ...
Pharmacotherapy of obesity: an update on the available medications and
Obesity is an epidemic and a public health threat. Medical weight management remains one of the options for the treatment of excess weight and recent advances have revolutionized how we treat, and more importantly how we will be treating obesity in the near future. Metreleptin and Setmelanotide are currently indicated for rare obesity syndromes, and 5 other medications (orlistat, phentermine ...
Obesity treatment, prevention and management
Obesity treatment, prevention and management. Can be used in individuals with a BMI of 40 or higher, as well as in children and pregnant. women. Limitations. The ratio of body water to fat-free ...
Treatment of Obesity with Thyroid hormones in Europe. Data from the
Purpose The use of thyroid hormones (TH) to treat obesity is unsupported by evidence as reflected in international guidelines. We explored views about this practice, and associations with respondent characteristics among European thyroid specialists. Methods Specialists from 28 countries were invited to a survey via professional organisations. The relevant question was whether "Thyroid ...
Doctors and patients' perspectives on obesity. A Q-methodology study
13. Obesity is more common among people with higher education and income: −1.807: GPs factor 2: 21. Physical activity improves health, regardless of weight: 2.079: 14. Obesity is a disease with several different causes: 2.052: 28. Early childhood is the time where food- and exercise habits are developed: 1.323: 24.
PDF Thesis the Effects of Obesity and Duration on The Energetics and
ized to bodyweight, obese children had a smaller rate of oxygen consumption (gross VO2/kg) than thenonobese group (p<0.001) and we found no difference in net VO2/kg between g. oups. Obese children exhibited greater metabolic rate (Egross and Enet, p<0.001 for both). When. ) acrossthe duration of.
Obesity: Only half of England has access to comprehensive ...
Treatments are being restricted by cash poor local services, with many patients being denied specialist drugs, surgery, and support. Elisabeth Mahase investigates Access to services across England for obesity treatment is severely restricted, an investigation by The BMJ has found. Patients in nearly half the country cannot get appointments with specialist teams for weight loss support and care ...
Semaglutide and tirzepatide lead to better blood sugar control and
Semaglutide and tirzepatide treatment lead to significant weight loss and improve blood sugar control in individuals with type 1 diabetes (T1D) who are living with overweight or obesity, research ...
FDA Approves First Treatment to Reduce Risk of Serious Heart Problems
Wegovy is also approved to reduce excess weight and maintain weight reduction long term in certain adults with obesity or overweight and certain children with obesity, for use in addition to a ...
Obesity: causes, consequences, treatments, and challenges
Obesity has become a global epidemic and is one of today's most public health problems worldwide. Obesity poses a major risk for a variety of serious diseases including diabetes mellitus, non-alcoholic liver disease (NAFLD), cardiovascular disease, hypertension and stroke, and certain forms of cancer (Bluher, 2019).Obesity is mainly caused by imbalanced energy intake and expenditure due to a ...
(PDF) The causes of obesity: an in-depth review
carbohydrate is a crucial factor in the obesity epidemic. 18 Soft drinks, alcoholic beverages and fast food tend to be calorie rich. In Britain, there has been a signi cant rise in the amount of ...
Obesity treatments being restricted by cash poor local services across
Patients in nearly half the country can't get appointments with specialist teams for weight-loss support and care, including treatment with drugs such as semaglutide. And in nearly one in five ...
Weight loss drug shows promise in helping children with obesity
Ultimately, 10.7% of the kids taking the drug discontinued treatment because of the side effects, which is aligned with the rate of serious side effects in teens and adults.
Eli Lilly invests $1.8 bln in Ireland sites to scale up Alzheimer's
Eli Lilly is investing $1.8 billion across two manufacturing sites in Ireland to boost production of its hugely popular obesity drug and a newly approved treatment for Alzheimer's, the drugmaker ...
A new threat to Merck's Keytruda, Moderna's cutbacks and more
A new threat to Merck's blockbuster cancer treatment, Moderna's cutbacks, and obesity drugs for kids. Manage alerts for this article; Email this article; Share this article;

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Decision-making in the management of obesity: a scoping review protocol

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Introduction

Material and methods

Statistical analyses

Baseline characteristics of all respondents

Baseline characteristics of respondents considering TH for obese patients

Demographics

National and regional variations

Prevalence of obesity

Gross national income and use of TH in obesity

National guidelines and use of TH in obesity

Plausible explanations for the use of TH in obesity

Acknowledgements

Author information

Authors and Affiliations

Contributions

Corresponding author

Ethics declarations

Ethical approval

Informed concent

Additional information

Supplementary Information

Supplementary file1 (DOCX 33 KB)

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Article Contents

Doctors and patients’ perspectives on obesity. A Q-methodology study

Setting and data sources

Data analysis

Factor 1 (patients): have knowledge about healthy food- and exercise habits and feel mistreated by health care providers

Factor 3 (patients): do not think that obesity has an impact on the quality of life and do not think they need any help

Factor 1 (GP): understand the patients and believe that health care provides insufficient support

Factor 2 (GP): believe that obesity is hereditary and an eating disorder

Factor 3 (GPs): obesity is not a lifelong disease but it is difficult to lose weight

Comparison to existing literature

Strengths and limitations

Author notes

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