Addressing weight gain
Lifestyle modification. Eating smaller portions, combined with restricting foods high in calories and fat, should be the first step. A simple suggestion to a patient to eat the same foods, but remove 20% of the portion, is a simple intervention akin to that of suggesting sleep hygiene practices for insomnia management. Under medical supervision or with referral to a dietician or nutritionist, more rigid caloric restrictions could be employed.
Commercial weight-loss programs, such as Weight Watchers or Curves, can be helpful; some insurers will only cover medications for weight loss if one of these programs have been tried or is used in combination with medication. Some patients might ask about extreme weight-loss measures, such as low-calorie diets combined with intense exercise programs that have been popularized in the media. Although the motivation to initiate and maintain meaningful weight loss should be encouraged, doing so in a more gradual manner should be the goal.
Addressing portion size is a good approach in the early stages of managing obesity. Restaurants often serve portions that have more calories than should be consumed in one meal. Visual cues can influence this trend; using smaller plates can help reduce caloric intake.15
Exercise, sustained for at least 45 minutes, can have long-lasting effects, with a small study showing an increase in metabolic rate of 190 ± 71.4 kcal (P < .001) above baseline for 14 hours after exercise.16 Endurance exercise training is associated with a significant decrease in total cholesterol, triglycerides, and low-density lipoprotein cholesterol, as well as an increase in the high-density lipoprotein level over a 24-week period.17
Encouraging an exercise regimen that is appropriate for your patient can help maintain weight loss. In small trials,18,19 high-intensity exercise was shown to help suppress appetite and decrease 24-hour caloric consumption by 6% to 11%.18
Psychotherapy can become an important intervention for initiating and maintaining weight loss. CBT can help patients recognize and modify lifestyle components, and reinforce behaviors that promote weight loss. This can come from setting realistic weight loss goals; preventing triggering factors that lead to overeating; encouraging portion control during meals; and promoting exercise habits.
In a small, randomized controlled trial (RCT) examining weight loss in obese women, those who underwent CBT and psychoeducation for 2 hours a week for 10 weeks in addition to dietary changes and exercise showed an average weight loss of 10.4 kg at 18-month follow-up, compared with weight gain of 2.3 kg in the control group.20 The short duration of treatment in this study might be desirable to reduce cost and utilization of services. Group formats also could be employed.
Motivational interviewing is a useful tool in addiction psychiatry and shows promise for treating obesity and overeating as well. The approach may differ slightly because weight-loss therapy involves behavior modification rather than behavior cessation. In a meta-analysis of data from RCTs exploring motivational interviewing and its use as an intervention for weight loss, those in the intervention groups experienced significant weight loss as indicated by BMI decreasing a standardized mean difference of −0.51, compared with control groups.21
Medical management considerations
Diagnostics. Recognition and early intervention are instrumental in successfully treating medication-associated weight gain. It is important to obtain any family history of obesity, diabetes, hypertension, and hyperlipidemia. This will likely indicate a patient’s risk for weight gain before initiating medication.
Obtain vital signs at every visit, including blood pressure. Monitoring weight at every clinical visit can be used to calculate and monitor BMI, while also asking the patient to maintain a log of weight measurements obtained at home. Measuring abdominal girth is important to watch for metabolic syndrome, although often this is the least measured variable.
Laboratory testing is helpful. Obtaining a baseline lipid panel and a fasting glucose level (consider measuring hemoglobin A1c in patients with diabetes) is warranted. Including thyroid markers, such as thyroid-stimulating hormone and thyroxine (free T4), might be important considerations, because inadequate management of hypothyroidism can complicate the clinical picture.
Follow-up testing should be ordered every 3 to 12 months to monitor progress if your patient is showing signs of rapid weight gain, or if BMI nears ≥30 kg/m². These guidelines generally are assigned for prescribing of SGAs, but can be applied when using any psychotropic with weight gain potential.
Medications to considerWhen considering the medication regimen as an intervention point, consider changing the antidepressant to one that is not associated with significant weight gain. Although not specifically indicated as a monotherapy for weight loss, switching to or augmenting therapy with bupropion could aid weight loss through appetite suppression.20 Some newer antidepressants, such as vilazodone, vortioxetine, and levomilnacipran, might have less propensity to cause weight gain. In patients with severe depression, augmenting with medications containing amphetamine or methylphenidate could cause some weight loss, but greater care should be taken because of cardiovascular effects and dependency issues.
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