Multidisciplinary Approach to Obesity Management: A Case Report

Summary

Obesity care is best delivered after in-depth initial screening and evaluation, using an individualized approach comprising multidisciplinary care, evidence-based lifestyle behavioral change strategies, and frequent follow-up. We illustrate a successful 6 month course of weight loss treatment, resulting in reversal of obesity-related chronic conditions and improvement in diet, sleep, mood, and physical fitness.

Abstract

Effective weight management care emphasizes a patient-centered approach that employs evidence-based tools and strategies to address the complex and multifactorial nature of obesity and prevent chronic obesity-related medical conditions. Successful outcomes hinge on personalized care, consistent engagement, and the integration of multiple interventions that are tailored to individual needs and circumstances. In the John Hopkins Healthful Eating, Activity and Weight Program (HEAWP), healthcare professionals specializing in obesity medicine work in partnership with other specialists, including behavioral therapists, dieticians, psychologists, psychiatrists, sleep specialists, bariatric surgeons, gastroenterologists, and physical therapists, while also involving patients in their own care.

Each patient starts with an in-person intake meeting with an obesity physician, during which information about their nutrition, sleep, mood, medications, social support, and physical exercise is evaluated. By the end of the visit, realistic goals are set in concert with the patient, and the patient is given specific tasks to assist them in accomplishing these goals. The initial phase of the intensive evaluation and treatment at HEAWP typically lasts 6 months, with follow-up medical visits every month. At that point, goals are reassessed and future treatment plans formulated. The average pace of weight loss is 1-2 pounds (0.4-0.9 kg) per week.

Introduction

Obesity has become an increasing global epidemic. Defined by the World Health Organization (WHO) as a chronic, multifactorial, and relapsing disease, obesity has reached pandemic proportions, with more than 1 billion people affected at increasing rates in nearly every country in the world^1,2. Obesity is a disease associated with hundreds of medical complications and early deaths. At least 5 million obesity-related deaths occur annually, ~12% of all deaths from noncommunicable diseases globally³. Global costs of obesity are predicted at $3 trillion per year by 2030 and account for up to 18% of national health expenditure in countries with prevalence rates of 30% for obesity^4,5. It is predicted that by 2035, nearly half of all adults in the world will suffer from obesity, and that by 2050, more than 250 million Americans will be suffering from overweight or obesity^4,5,6.

Weight reduction of as little as 5% has been shown to improve and even reverse many chronic medical conditions associated with obesity^7,8. However, lack of adequate numbers of obesity specialists, as well as the lack of specialized training and resources for health care providers in this field, have placed limitations on the ability of most primary care doctors to effectively treat obesity⁹. Underdiagnosis and the tendency to approach obesity exclusively by treating its complicating conditions, such as diabetes and cardiovascular disease, has led to further problems. Further, weight management, when conducted in a multidisciplinary setting, allows better access to other specialties, such as bariatric surgery, endocrinology, and gastroenterology, and thus can lead to better clinical outcomes¹⁰. Finally, disparities in the prevalence of obesity and the availability of evidence-based treatment in underserved and minority populations is a major challenge in tackling the obesity crisis broadly and effectively¹¹.

The approval of new and more effective anti-obesity medications, such as glucagon-like peptide-1 receptor agonists (GLP-1 RA) and dual GLP-1 and gastric inhibitory polypeptide-1 (GIP-1) receptor agonists, as well as others in development, has galvanized an increase in the attention given to obesity care. These new incretin drugs are potentially transformative. They lead to mean reductions in body weight of up to 25% in randomized, controlled clinical trials, along with improvements in a range of other conditions, notably cardiovascular disease, diabetes, kidney dysfunction, and sleep apnea^12,13. Approval for the use of semaglutide (GLP-1 RA) by the US Food and Drug Administration was granted in 2021 for the treatment of obesity^12,13 and for tirzepatide (dual GLP-1/GIP RA) in 2023. Now more than ever, healthcare systems will need to prioritize the delivery of more effective and individualized obesity care. This has the potential to greatly improve a wide range of obesity-related complications and promote health and longevity for those suffering from this widespread, but still often undertreated condition.

Case Presentation:

The patient is a 52-year-old male with a BMI of 46 kg/m² (class III obesity), prediabetes, hypertension, depression, and a surgical history of a left meniscus repair. He is married and works as an engineer. His medications include bupropion XL 300 mg daily, metoprolol XL 100 mg daily, amlodipine 10 mg, and chlorthalidone 25 mg.

During his initial visit as a new patient to HEAWP, he noted that his current weight, 361 pounds (164 kg), has been his highest weight. He reported gaining more than 100 pounds (45 kg) over the past 25 years since graduating from college, attributing it to a progressively sedentary lifestyle and work-related demands, which led to increased consumption of processed foods. Previously, he had multiple failed attempts to lose weight, including intermittent fasting, whereby he initially lost 25-30 pounds (~11-14 kg) but regained them as he was unable to sustain that diet over time.

A 24-hour diary recall revealed that the patient was skipping breakfast, ate a moderate-sized salad for lunch, and consumed his largest meal of the day at dinner, which typically included a protein, a starch, and vegetables. He consumed sweet tea with his meals and alcohol on social occasions only. Describing his sleep pattern, the patient reported sleeping 5-8 h per night, an inconsistent schedule, difficulty falling asleep, and occasional interruptions to urinate. He reported that he often goes to bed late after watching TV or spending time on his phone in bed. He was diagnosed with sleep apnea 4 years ago and uses continuous positive airway pressure (CPAP) therapy regularly. Screening for depression using the Patient Health Questionnaire-2 (PHQ-2) score indicated mild depression; screening for eating disorders, including binge eating disorder (BED), was negative. The patient reported a stressful working environment but endorsed social support from his wife and friends. His daily routine included working from home and sitting at his desk. Although he attempted to exercise in the past, he reported not engaging in any physical activity.

At his initial visit to HEAWP, the patient weighed 361 pounds (164 kg), height 6 ft 2 in (188.8 cm) with a BMI of 46 kg/m². His blood pressure was 138/94 mmHg, and his pulse was 91 bpm. On physical examination, his Mallampati score was 4, and his neck circumference measured 17 inches (43 cm). The rest of the exam was unremarkable except for abdominal obesity. Laboratory results were significant for glucose of 105 mg/dL, HbA1c of 6.1%, total cholesterol of 220 mg/dL, LDL of 140 mg/dL, HDL of 35 mg/dL, triglycerides of 190 mg/dL, ALT of 60 U/L and AST of 55 U/L, while TSH was 1.5 mIU/L. Abdominal ultrasound was supportive of mild Metabolic Dysfunction-Associated Steatohepatitis, Fibrosis-4 Index (Fib-4). The patient's primary goals were to reverse the recently diagnosed prediabetes and steatohepatitis and start losing weight.

Diagnosis, Assessment, and Plan
A typical program at HEAWP includes a comprehensive, in-person, initial evaluation and multiple follow-up visits. During the initial encounter, a detailed history of each patient's eating habits, weight history, sleeping patterns, mood, social support, and exercise routine is recorded. Each patient's medication list is checked for potential weight-promoting medications, and if possible, weight-neutral, alternative medications are suggested. Further, close attention is given to potential contributing factors for obesity, obesity-associated conditions, relevant laboratory test values, and the potential for improvement and even reversal of any obesity-associated co-morbidities with weight loss. These associated conditions include hypertension, prediabetes, type-2 diabetes, hypercholesteremia, obstructive sleep apnea, and metabolic-dysfunction-associated steatotic liver disease. Most patients also undergo a metabolic rate test, checking for their daily caloric demand, and a non-invasive body composition analysis that uses a tiny electrical current to measure percent body fat, muscle, and water. After the initial assessment, a customized plan is constructed aiming to address the reason for weight gain and control possible obesity-related complications. In-house, as well as external, referrals to any needed specialists are made. For example, if a reason for overconsumption of food is found to be binge eating, the patient is referred to a robust cognitive behavioral therapy-based program and seen by a specially trained psychologist with the goal of addressing their bingeing habits. If sleep disturbance seems to be a problem, referral to a sleep specialist may be initiated.

The intensive weight loss program includes multiple interventions, such as nutritional changes, pharmacological management of anti-obesity medications, sleep intervention, an exercise program, and addressing possible disordered eating related to food. A meal replacement program is also available for patients who may benefit from being directly provided with controlled-portion foods in the earlier stages of weight loss. These meal replacements are low-fat, low-carbohydrate, and high-protein to maximize satiety with caloric control. Realistic goals regarding weight loss are set, and most importantly, patients are educated about ways to sustain the weight loss achieved. For most patients, the weight loss goal is 0.5-1 pounds (0.2-0.4 kg) per week, with an overall 5-10% or greater loss of their starting weight in 4-6 months.

New patients have the option of joining group visits, which are based on a scientifically proven lifestyle change curriculum, adapted from the Look AHEAD (Action for Health in Diabetes) Trial. Participants complete a self-guided online orientation and attend biweekly group sessions led by an obesity medicine physician, combining structured lessons, group discussions, and a separate one-on-one visit for each group member. Group meeting topics include healthy eating, problem-solving, and motivation. A minimum 6 month (18 sessions) commitment is recommended. The groups provide a safe and potentially empowering space for participants, who may share their struggles and accomplishments, and can obtain guidance and support in their weight loss journey. The groups can foster a sense of belonging, reducing the social isolation that can occur in the face of obesity, as well as reinforce accountability. By the end of each group session, the facilitator of the group meets with each participant individually to address their specific concerns, review any medications, and suggest a plan for the next weeks.

Between visits, patients are encouraged to communicate any pressing problems with their obesity physician electronically. Future visits are designed to follow up on previous goals and reflect upon their interim experience. In the event of not meeting their goals, new strategies are formulated, and adjusted goals set. Often, other interventions, such as changing or increasing doses of medications, modifying a nutritional plan, or even considering surgical intervention for weight loss are discussed. The programs at HEAWP are patient-centered and consist of collaborations between the patient and the healthcare provider. The broad goal is to use a variety of evidence-based tools to help patients make long-term changes to improve their health by preventing or managing chronic disease.

The patient presented with Class III obesity, hypertension, prediabetes, and depression. His diet consisted of skipping meals and had high amounts of sugars and simple carbohydrates. He did not have a structured exercise plan, and his sleep quality was subpar. The initial plan was to improve these aspects of his lifestyle in every visit and to start a weight loss trend using medication.

Over the course of a year, the patient had close follow-up with the team at HEAWP that included nine in-person visits and customized weight loss interventions, with an emphasis on reversing his obesity-related conditions. He was provided with options for a detailed nutrition plan, emphasizing a balanced diet consisting of healthy plating, proper portions, and the elimination of processed food. For his diagnosis of prediabetes, he was advised to avoid products with added sugars and limit consumption of simple carbohydrates. His diet included a healthy, lower-fat source of proteins, such as chicken and fish, and fiber, mostly from fruits and vegetables. He was advised to gradually reduce his consumption of sweet tea and replace it with a product that has no added sugars and less than ten calories per serving. The plan's caloric value was 1,900 calories/day, designed to lead to 500 calorie daily caloric deficit, based on his calculated resting metabolic rate of 2,400 calories/day. He was encouraged to track his caloric intake using an application on his cell phone and track his protein intake (which gradually increased as his exercise program and weight loss goals changed through the year).

At his second visit, he was prescribed Qsymia (phentermine/topiramate). As the patient's appetite started to decrease, he averaged a weight loss of 1-1.5 pounds (0.45-0.7 kg) per week. As his weight loss proceeded, his caloric deficit narrowed, and his diet had to be adjusted accordingly, ensuring ongoing weight loss and sufficient intake of macro- and micronutrients according to dietary guidelines. At his third visit, a second anti-obesity medication, tirzepatide, was added at a starting dose of 2.5 mg weekly, increasing over the course of the year to 12.5 mg weekly. The patient was also provided with information about sleep hygiene and encouraged to start a sleep routine. That included minimizing screen time prior to sleep, engaging in relaxing meditation, and eliminating lights and noises from the bedroom. He structured a sleeping schedule and avoided screen time hours before bedtime. He reported better and deeper sleep and less daytime sleepiness.

In each of the subsequent visits, close attention was given to the patient's nutrition program, sleep quality, exercise plan, and stress management -- all of which improved as he reduced his weight. The patient kept a record of his ambulatory blood pressure, which was measuring on average 110/80. After a 10% weight loss, he was able to stop taking one of his blood pressure medications, chlorthalidone. He continued to report normal range ambulatory blood pressure readings, and his other blood pressure medication, amlodipine, was gradually titrated down, from 10 mg, to 5 mg, 2.5 mg, and subsequently discontinued.

A structured, customized exercise program was an integral part of the patient's program at HEAWP. His former injury and left meniscus repair had to be taken into consideration. For the first few months, the patient walked an average of 6,000 steps per day. As his weight loss progressed over the course of the year, he was able to increase his steps to an average of nearly 20,000 steps daily; he tracked his daily steps and communicated his progress with the team at HEAWP. Halfway through his journey, the patient started a strength training program, emphasizing increasing his muscle mass. He was provided with a program consisting of selected body movements for each major muscle group: upper body, lower body, and core. The program included movements such as back squats, deadlifts, overhead presses, loaded suitcase carries, seated single-arm low rows, and stagger stance single-arm chest presses. Each movement had three working sets and 8-10 repetitions. The patient sent back videos from the gym to his obesity provider for feedback. Later, he had an in-person meeting with the physical therapy team, which provided further education about proper movement, avoidance of possible injury, and introduction of new movements for building muscle.

Protocol

1. Initial evaluation visit at HEAWP

1. Weight history
   1. The physician reviewed current weight and recognized weight trends. The patient reflected on the current trend and on previous successful and unsuccessful weight loss attempts.
2. Past medical history
   1. The physician and the patient reviewed the list of known medical conditions, their year of diagnosis, and their current treatment
3. Obesity-related comorbidities and their severity
   1. Specific obesity-related comorbidities were discussed, including current and past treatment, and their lab values
4. Medication review
   1. All medications were reviewed with an emphasis on potential weight-promoting medications.
5. Lab results
   1. Recent obesity-related lab value trends, such as the lipid panel, A1c / fasting glucose, liver enzymes, TSH, and T4, were reviewed and discussed.
6. Imaging results
   1. The physician performed a screen for radiological evidence for Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD).
   2. Previous body composition scans were reviewed.
   3. Breathing test results-RMR (Resting Metabolic Rate) value-were reviewed.
7. A 24 h dietary recall was conducted.
   1. Sleeping habits and schedule were discussed.
   2. The physician screened for Obstructive Sleep Apnea by reviewing the Sleep history, including past studies, adherence to CPAP and sleep hygiene techniques.
8. Behavioral triggers for weight gain were examined by screening for depression and anxiety, binge eating syndrome, and emotional eating.
9. Physical activity level
   1. The current status of physical exercise was reviewed and the patient reflected on previous enjoyable activities.
   2. Physical limitations (history of injuries, pain levels, etc.) were reviewed.
10. Female patients:
    1. Mensural cycle regularity and abnormalities were discussed.
    2. The physician conducted a screen for menopause and perimenopause symptoms.
    3. The physician also conducted a screen for Polycystic Ovarian Syndrome.

2. Physical exam

1. A regular basic physical exam was performed.
2. BMI, waist circumference, and Mallampati score were calculated.

3. Planning

1. Long- and short-term goals in terms of weight and non-weight related comorbidities were discussed.
2. Nutritional plan
   1. Dietary recommendations were provided, based on goals and co-morbidities
3. Exercise plan
   1. A plan was recommended, based on goals, schedule, physical limitations, and available resources.
4. Medications
   1. Anti-obesity medications were discussed, based on weight goals and comorbidities.
   2. Suggestions were provided regarding changing current weight-promoting medication(s) to weight neutral medication(s).
5. Follow up lab work and other testing relating to comorbidities were discussed.
6. A follow-up appointment was scheduled.

4. InBody Test Protocol (see Supplemental File 1)

1. Ask the questions listed in Supplemental File 1 prior to starting the test.
2. If the answer is "no," perform the exam after preparing the patient for the test.
3. Complete the test and print the results.

5. Resting Metabolic Rate Breathing Test Protocol (see Supplemental File 2)

1. Calibrate the device to measure the patient's vitals, weight, and height.
2. Ask the questions listed in Supplemental File 2 prior to starting the test.
3. If the answer is "no" to all questions, perform the test, enter the patient's data into the machine, print out the results, explain their meaning to the patient, and answer any questions.

Results

After a year, the patient had lost 66 pounds (30 kg), reducing his weight by 18%, from 361 to 295 pounds (from 164 to 133 kg), and his BMI declined from 44 to 37 kg/m² (see Supplemental Table S1). That reduction in weight helped him control his blood pressure without medications, reverse his prediabetes, improve his fatty liver, and eliminate the pain he had formerly suffered when working out. This weight loss was achieved using a dynamic nutritional plan, a customized exercise plan, improveme...

Discussion

The past few decades have brought a shift in medicine's approach to obesity and its treatment. Historically, obesity was considered a result of personal choices, such as overconsumption of calories and physical inactivity, and treatment options were limited. It is now clear that obesity is caused by a myriad of causes, spanning behavioral, environmental, and genetic factors that may have resulted in appetite dysregulation, where hormonal and neural mechanisms that regulate hunger and satiety become unbalanced

Materials

Name	Company	Catalog Number	Comments
Medications
1.      Phentermine-topiramate (Qsymia) 3.75-23 mg	Vivus Inc.
2.      Tirzepatide (Mounjaro) 7.5 mg	Eli Lilly
Equipment
1.      Blood pressure digital reader
2.      InBody Body Composition Analyzer		(Model: InBody 770)
3.      MetaCheck metabolic analyzer	Korr Medical Technologies
4.      Apple Watch
Software
1.      Epic, Electronic Health Record
2.   MyChart for communication