Nutrition in Cardiometabolic Risk

Speaker: Linda M. Delahanty, MS, RD, LDN, and Donna Ryan, MD

With a growing number of obese people in the United States, healthcare professionals are seeking the best way to treat the epidemic. Options include promoting a healthier diet and more exercise, performing surgery, or prescribing medications. 

In the summer of 2012, the FDA approved 2 oral drugs (lorcaserin and the combination of phentermine and topiramate extended release) for chronic weight management. In addition, surgical options are becoming more common and safe.

Still, speakers at the 2013 Cardiometabolic Risk Summit said treating obesity is difficult because it is a chronic condition and people tend to regain the weight they lost. 

Dietary Modifications

Linda M. Delahanty, MS, RD, LDN, chief dietitian at the Massachusetts General Hospital Diabetes Center, said if someone asks her what to eat to lose weight, she says it’s not a simple, straightforward answer. She said people are “overwhelmed” when it comes to what they should eat because there are so many guidelines. 

The American Diabetes Association recently released recommendations for people with prediabetes or type 2 diabetes.1 The organization suggests losing 7% body weight, exercising for 150 minutes per week, having saturated fat account for less than 7% of total calories, minimizing the intake of trans fat, and drinking a moderate amount of alcohol (2 or fewer drinks per day for men and 1 or fewer drinks per day for women).

A common goal in reducing weight is lowering a person’s low-density lipoprotein (LDL) cholesterol. A 2002 report from the National Cholesterol Education Program2 found:

• If the saturated fat in people’s diet accounts for less than 7% of their calories, it will lead to an 8% to 10% reduction in LDL cholesterol.

• Having less than 200 mg per day of dietary cholesterol leads to a 3% to 5% reduction in LDL cholesterol. 

• Losing 10 pounds leads to a 5% to 8% reduction. 

• Eating 5 g to 10 g per day of viscous fiber leads to a 3% to 5% reduction.

• Consuming 2 g per day of plant sterol or stanol esters leads to a 6% to 15% reduction. 

Another study that examined the effect of lifestyle modifications on systolic blood pressure found:3 

• Losing 10 kg led to a 5 mm Hg to 10 mm Hg reduction in systolic blood pressure.

• Having a diet with an increase in fruits, vegetables, and low fat dairy and a decrease in saturated and total fat led to a 8 mm Hg to 14 mm Hg reduction.

• Consuming 2400 mg per day of dietary sodium led to a 2 mm Hg to 8 mm Hg reduction. 

• Having 2 or fewer alcoholic drinks for men and 1 or fewer drinks for women led to a 2 mm Hg to 4 mm Hg reduction.

• Exercising for 30 minutes per day led to a 2 mm Hg to 4 mm Hg reduction. 

Results from the Diabetes Prevention Program showed that it is possible to teach people how to lose weight. The study included 3234 adults who were overweight and had prediabetes—and found that a weight loss and physical activity regimen proved more effective than a metformin drug regimen.4 For every kg of weight loss, people reduced their risk of diabetes by 16%.5 

Although opinions vary on the best ways to achieve weight loss, Delahanty said that the most effective option to reduce diabetes and other cardiovascular risk factors is to lose 5% to 10% body weight.

“All the rest of this will fall into place [if people have a good diet],” said Delahanty.

Drug Options

Donna H. Ryan, professor emeritus at Pennington Biomedical Research Center in Baton Rouge, LA, noted that weight loss of 5% to 10% can prevent type 2 diabetes, increase LDL cholesterol, reduce blood pressure, triglycerides, and C-reactive protein, and improve glycemic control, mobility, markers of non-alcoholic fatty liver disease, and symptoms of sleep apnea and depression. The benefits are found regardless of a person’s body mass index (BMI).

However, the strategies used to reduce weight sometimes differ from those implemented to sustain weight loss. To keep from gaining pounds, people must comply with their medications, regularly monitor their weight, and exercise on a consistent basis. She said clinicians and researchers search for a “magic cure” to obesity, but they should instead treat the condition for the long-term.

“We must manage obesity like a chronic disease,” Ryan said.

Whereas people used to be required to pay for weight loss and obesity drugs out-of-pocket, the landscape has changed. Ryan said today 40% of health plans reimburse the drugs, and she expects the percentage to increase as the medications become more acceptable.

Medications on the market include:

Phentermine, approved in 1959, is cheap but it comes in high doses and is only approved for 3 months of use and medical societies “frown upon” using phentermine for any longer.6 Common adverse effects include restlessness, insomnia, and an increase in pulse and blood pressure.

Orlistat is more expensive than phentermine, but it can be used for up to 4 years. Common adverse effects related to orlistat include gastrointestinal symptoms and an increase in urinary oxalate.7 

Phentermine and topiramate. In July 2012, the FDA approved the combination of phentermine and topiramate extended release in 2 dailydoses: 7.5 mg of phentermine and 46 mg of topiramate (recommended dose) as well as 15 mg of phentermine and 92 mg of topiramate (for certain patients). It is approved for people with a BMI of 30 kg/m2 or greater or those with a BMI of 27 kg/m2 or greater with at least 1 weight-related condition.

After 2 years of treatment, patients who received phentermine and topiramate had a significant reduction in hemoglobin A1c (HbA1c) as well as a decrease in the number of diabetes medications they received compared to a placebo group.8 Common adverse effects associated with the combination drug include dry mouth, tingling, constipation, altered taste sensation, and upper respiratory infection. 

Lorcaserin. The FDA approved lorcaserin in June 2012 for the same patient population as the combination of phentermine and topiramate. It is approved in a 10-mg dosage taken twice daily. A 1-year, randomized, placebo-controlled study of patients with type 2 diabetes found that lorcaserin led to a significant reduction in HbA1c and the use of diabetes medications compared with patients who received placebo.9 Common adverse effects associated with lorcaserin include headache, dizziness, and nausea.

Although both lorcaserin and phentermine and topiramate extended release are effective at reducing weight and improving glycemic control, Ryan said that the latter leads to more weight loss. However, as with all weight loss drugs, patients do not typically take them for a long time due to adverse effects or other reasons. Ryan said she asks her patients to use the medications for at least a year.

Surgical Options

Patients can also choose to undergo surgery to manage their weight, although Ryan suggested they first read the recently updated guidelines from the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), and the American Association of Metabolic and Bariatric Surgery (ASMBS). 

Ryan recommends patients attempt lifestyle modifications and consider the available pharmacotherapies, such as lorcaserin and the combination of phentermine and topiramate, before an operation. The AACE/TOS/ASMBS guidelines10 indicate that surgery should be used only after people fail to lose weight with non-surgical options, including non-professional programs (eg, Weight Watchers). 

Surgery is most effective for the 5% of people in the United States with a BMI >40 kg/m2, according to Ryan. The AACE/TOS/ASMBS guidelines note that surgery should be considered in people with a BMI of at least 40 kg/m2 or people with a BMI of at least 35 kg/m2 as well as obesity-associated comorbidities.10

“Bariatric surgery can produce significant health benefits, and it can be life saving,” she said.

As of October 2013, more than 250,000 weight loss surgeries had been performed in the United States, according to Ryan. The 3 most common surgeries are laparoscopic adjustable gastric band, gastric sleeve, and Roux-en-Y gastric bypass. The gastric band and gastric sleeve procedures cost $10,000 to $15,000, while gastric bypass costs $20,000 to $25,000.11,12 

Ryan said that gastric bypass leads to the greatest weight loss, but it is the least safe option and requires lifelong vitamin and mineral supplementation. Gastric band is the safest procedure, although it leads to less weight loss than the other options and requires adherence for the greatest efficacy.

All of the surgical options are associated with gastrointestinal complications, such as disruption of diet as well as nausea, vomiting, and gallstones. Band erosion and displacement are more often found in people undergoing gastric banding, while internal hernias and obstruction, anastomic complications, and suture-line and staple-line complications are more common in people undergoing gastric bypass. ■


1.American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(Suppl 1):S11-S66.

2.Bonow R. Primary prevention of cardiovascular disease: a call to action. Circulation. 2002;106(25):3143-3421.

3.Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289(19):2560-2572.

4.Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.

5.Hamman RF, Wing R, Wylie-Rosett J. Effect of weight loss with lifestyle intervention on risk of diabetes. Diabetes Care. 2006;29(9):2102-2107.

6.FDA. Available at: Accessed February 2014.

7.FDA. Available at: Accessed February 2014.

8.Garvey WT, Ryan DH, Look M, et al. Two-year sustained weight loss and metabolic benefits with controlled-release phentermine/toiramate in obese and overweight adults (SEQUEL): a randomized, placebo-controlled, phase 3 extension study. Am J Clin Nutr. 2012;95:297-308.

9.O’Neil P, Smith S, Weissman N, et al. Randomized placebo-controlled clinical trial of lorcaserin for weight loss in type 2 diabetes mellitus: the BLOOM-DM study. Obesity. 2012;20:1426-1436.

10.Mechanick JL, Kushner R, Sugarman H, et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Endoc Pract. 2008;14(suppl 1):1-83.

11.Payne JH, DeWind LT. Surgical treatment of obesity. Am J Surg. 1969;118:141-147. 

12.Hocking MP, Duerson M, O’Leary J, Woodward E. Jejunoileal bypass for morbid obesity—late follow-up in 100 cases. N Engl J Med. 1983;308:995-999.