What can providers do to help patients manage their weight before and during menopause?
This is the question Kara Marlatt, MPH, PhD sought to answer during her presentation at the North American Menopause Society’s (NAMS) 2021 Annual Meeting: Triangulating Weight Loss: Behavior, Medicine, and Surgery1.
There are things all clinicians must know before implementing weight management in primary care. The factors that contribute to the body’s defended fat mass include abnormal diet, poor sleep, stress, sedentary behaviors, and weight gain-inducing drugs. “The body really wants to defend its current state,” Marlatt said. “For example, if you’ve just finished working out, you might want to lie on the couch for a little bit longer. There are systems in place to help the body really defend that fat mass.”
So how do we combat this weight gain, particularly the fat mass that occurs?
“The first line of defense is behavior modification,” Marlatt continued. This includes encouraging a healthy diet, regular physical activity, more and better sleep, stress reduction, stable eating patterns, and weight stabilizing alternatives. Marlatt noted that these things may even need to be treated before they can be successful.
In instances where behavior modification alone appears insufficient, there are anti-obesity medications that are available, said Marlatt, “And there are even better ones that are coming down the pipeline that will be game-changers for weight loss.” However, in severe cases, bariatric surgery may be considered.
Marlatt’s presentation outlined the different therapeutic options for obesity and weight management. As mentioned earlier, behavior modification should always be the first-line treatment. Utilizing a team-based approach and referring patients to RDs with weight management certification, or even commercial programs like WW, formerly known as weight watchers, may also prove successful. For adjunct therapies, there are pharmacotherapy options.
For patients needing treatment beyond lifestyle modification, bariatric surgery may be the best course of action but should be reserved for severe cases. In these cases, it could elicit 30 to 40% weight loss.
- Educate your patients on changes that occur during menopause, and don’t wait until they’re in the trenches to start the conversation.
- Many health improvements can be seen from 5%, 10%, and 15% weight loss.
- If weight loss proves challenging, focus on weight maintenance and/or combined use of weight loss medications.
The use of intensive lifestyle intervention and older weight loss medications, such as orlistat and liraglutide, showed up to 10% weight loss. However, Marlatt said, the older medications produced major side effects. Bupropion, for example, increased blood pressure.
“Thankfully, in the next few years, primary care providers will be able to use new biologic medications more often,” said Marlatt. “What is good about these newer drugs is that they are derived from natural peptides that will be more stable, not as easily degraded, and have extended-release properties.”
Semaglutide 2.4 mg weekly is one of the medications that Marlatt views as a major gamechanger, with which she is seeing an average of 15 to 17% weight loss. Phase 2 results for Bimagrumab were just published in JAMA Network Open2, which demonstrated significant results of reducing fat mass while increasing fat-free mass, which Marlatt said should be the main goal of the newer drugs on the market.
Marlatt called attention to the under-prescription of anti-obesity drugs, noting that only 1.3% of eligible persons are given a prescription3.
What do your patients need to be successful at losing weight?
Increasing physical activity beyond 2400 kcal/week has proven a successful tactic, as has maintaining dietary vigilance and continuing to use medications that target weight loss, or that target factors related to increased energy intake and reduced energy expenditure
In her research, Marlatt found that social support and accountability was the primary need. “These women wanted other women like them, who were experiencing the things they were experiencing. They wanted validation for the things that they were feeling,” Marlatt said.
The second need was more menopause education. By having more information on what was going to happen, women felt empowered and more in control.
The current barriers to prescription are higher than desired, but Marlatt encourages practitioners to stay patient. “In the next few years, there will be approval for reimbursement, so just know they are coming! We just need to be patient a little while longer,” she concluded.
- Marlatt, Kara. 21 September 2021. Triangulating Weight Loss: Behavior, Medicine, and Surgery [Session]. North American Menopause Society, Washington, D.C.
- Heymsfield SB, Coleman LA, Miller R, et al. Effect of Bimagrumab vs Placebo on Body Fat Mass Among Adults With Type 2 Diabetes and Obesity: A Phase 2 Randomized Clinical Trial. JAMA Netw Open. 2021;4(1):e2033457. doi:10.1001/jamanetworkopen.2020.33457
- Saxon DR, Iwamoto SJ, Mettenbrink CJ, et al. Antiobesity Medication Use in 2.2 Million Adults Across Eight Large Health Care Organizations: 2009‐2015. Obesity. 2019;27(12):1975-1981. doi:10.1002/oby.22581