By Bartolome Burguera, MD, PhD, Kelly Nocero, RN, Dawn Noe, RD, Cheryl Reitz ,RD, Kathryn Corte, RD, Emily Bostin, RD, Melissa Matthews, NP, and Beth Abood, RN

The prevalence of morbid obesity (body mass index [BMI] ≥ 40 kg/m²), has become an epidemic. People with morbid obesity have a significant risk of developing medical complications, such as cardiovascular disease, Type 2 diabetes, dyslipidemia, hypertension, sleep apnea, depression and certain types of cancers. Obesity also increases all-cause mortality.

Bariatric surgery is currently the most effective therapy to treat morbid obesity. However, the current rate of utilization of bariatric surgery is only 1/100th of the entire existing morbidly obese population.

Despite the fact that so few patients opt for bariatric surgery, it is becoming evident that conventional approaches to obesity therapy have very limited effects, as the Swedish Obesity Study and other studies — including ours — have shown. Therefore, it’s imperative that we develop effective obesity interventional therapies as alternatives to bariatric surgery.

In response to that need, we set up an intensive lifestyle intervention program based on scientific evidence for patients with morbid obesity who are not candidates for, or are not interested in, undergoing bariatric surgery. Shared medical appointments (SMAs) are at the heart of this novel program.

The value of intensive lifestyle intervention

There are already an important number of studies showing the beneficial effects that behavioral therapy,  along with pharmacotherapy, have on weight loss—with a resulting improvement of diseases associated with obesity. Some of these reports have shown the beneficial effects that even a small weight loss can have on improving the general health of obese individuals.

We previously have shown that morbidly obese patients who received an intensive lifestyle intervention had a greater percentage of weight loss than patients receiving conventional obesity therapy (–11.3 percent vs. –1.6 percent).⁶ Of note, 31.4 percent of patients included in the intensive lifestyle intervention group, were no longer morbidly obese after just six months of intervention.

How our program works

Our SMA intensive lifestyle intervention program focuses on giving patients the therapeutic tools they need to become more accountable and to slowly obtain control over their weight.

We focus on the following five areas to support our patients in losing weight and keeping it off:

• Nutrition: Patients are encouraged to slowly change their eating habits. Throughout the program, new behaviors are introduced to facilitate healthy habits. In conjunction with our dietitians, we review food quality, quantity and portion sizes, as well as types of drinks consumed.

After visiting with our nutrition team, patients can choose from three dietary programs:

• Protein-Sparing Modified Fast: Patients eat mainly lean meat, seafood, poultry and a limited amount of low-carbohydrate vegetables. Additional carbohydrates and fats are not permitted.
• Mediterranean dietary plan: Patients eat legumes, unrefined cereals, fish, poultry, fresh fruit, olive oil as the principle source of fat and dairy products (primarily cheese and yogurt). Red meat can be consumed in low amounts, and wine can be consumed in low to moderate amounts.
• Meal replacement: Patients have a protein shake or bar at breakfast and lunch, a balanced dinner, and one to two snacks throughout the day.
• Physical Activity: Patients receive a physical activity plan tailored to their fitness level and medical status. Our exercise physiology colleagues in Cardiac Rehabilitation evaluate the cardiac status of a large number of our patients. Activity plans typically consist of upper body exercises, water exercises, swimming, walking, jogging, bicycling, etc. Patients are encouraged to set short-  and midterm exercise goals.
• Appetite control with weight loss medications: It is well known that after an initial weight loss, the body turns on compensatory mechanisms that increase hormones associated with increased appetite. It is important that we counter-balance these effects with the use of appetite suppressants. We review the pros and cons of these medications with patients before initiating therapy.There are currently six weight loss medications on the market, and five of them have been shown to reduce appetite. These medications reduce the appetite set point in the brain, which results in a feeling of satiety after eating fewer calories. For many patients, not being hungry is a new feeling, which allows them to make better food choices.

• Healthy sleep habits: It is important that patients rest well during the night so they are not tired in the morning, and they can be more physically active throughout the day. Also, lack of sleep is associated with increased appetite. We work closely with our colleagues in the Sleep Disorders Center to address this issue and to assess whether patients have restless leg syndrome, obstructive sleep apnea or other sleeping disorders that require treatment.
• Stress control: The prevalence of anxiety, depression, eating disorders (such as food addiction, bulimia and binge-eating disorder) and other psychiatric conditions is significant in patients with morbid obesity. Many of these patients may benefit from anti-anxiety and/or antidepressant therapy. Our psychologist colleagues in the Bariatric & Metabolic Institute assist with behavior modification and therapy in the context of SMAs.

Patients first have an individual appointment and then follow-up monthly visits together with a physician and dietitian, in the context of SMAs.

The 90-minute SMAs are carried out by a physician, a dietitian, nurse and medical assistant. Every SMA group includes five to seven patients. All of them are following one of the three dietary programs. Once a group is formed, it usually stays the same and no new patients are added.

During each visit, we review the five areas detailed above. We also briefly review any endocrine issues that patients are having. We work closely with the patients’ primary care physician (an endocrinologist).

Encouraging first-year outcomes

Since initiating this program one year ago, 200 patients (including approximately 40 Cleveland Clinic employees) have participated. At six months, approximately 65 percent of the patients who started the program stayed enrolled. The average weight loss is 10 percent of the initial body weight after six months. It is well known that obese patients with comorbidities who lose 5 percent to 10 percent of their initial body weight reduce their cardiovascular risk.

The level of program acceptance by our patients is significant. They appreciate the knowledge, motivation, encouragement, therapeutic tools and sense of accountability that the program provides. Patients especially enjoy the positive support from their peers during the SMAs. They learn from other people’s successes and failures as well as their own. At the same time, the program is individualized, with an emphasis on identifying the best approach for every patient.