Clinical Practice Recommendations for the Management of Obesity in the United Arab Emirates Open Access

Obesity is defined as an abnormal or excessive fat accumulation caused by an imbalance between calories ingested versus calories expended [1,2]. It is this excessive body fat which has accumulated that impairs bodily health and predisposes individuals to a range of chronic diseases such as heart disease, hypertension, stroke and diabetes which can lead to disability and death [3], or to debilitating conditions such as osteoarthritis, respiratory disorders and clinical depression which affect the quality of life (QoL) [4]. Obesity is also influenced by genetic, environmental and lifestyle factors [3]. Common measures of obesity include the BMI, waist circumference and waist-to-hip circumference ratio [3].

With rapid urbanisation and improved living conditions as a result of rising incomes in Gulf Co-Operation Council (GCC) countries, obesity has become a major and growing health problem for the region [5,6,7,8]. The mean BMI for male and female patients visiting primary care physicians was found to be 28.2 and 28.7 kg/m² and for WC 98.2 and 93.4 cm respectively [9]. The United Arab Emirates (UAE) has a resident population of 9.3 million (in 2016), many of whom (85.5%) lived in urban areas and led sedentary lifestyles [10]. Based on the World Health Organisation (WHO) estimates for 2010, 25% of Emirati men and 40% of the women were obese [5]. Obesity rates in this country has doubled from 16 to 34% compared to 2000, and severe obesity (BMI ≥ 40 kg/m²) has risen dramatically from 2 to 11% [11]. This trend of rising obesity rates is especially alarming among its school-going children: 11.5-41.2% of them were found to be overweight or obese depending on the age group. The highest rate was in the age group of 11-14 years [12].

With the prevalence of obesity, obesity-related complications are also on the rise in the UAE. There is a need for concerted effort to implement robust preventive measures to control and diffuse this problem. Obesity, when associated with diabetes, imposes a great economic burden, and the prevalence of this disease and its complications is increasing worldwide [13]. Obesity is also ranked second to depression in terms of its cost to employers [14].

Obesity is a chronic disease that needs life-long management. It requires coherent strategies to prevent the progression from normal weight to overweight to obesity and regaining weight after weight loss [1]. A number of international guidelines for the management of obesity are already available in public domain [15,16,17,18,19,20]. However, local guidelines for the UAE and the region, which are structured and individualised for the management of obesity, are sorely needed to help the family physician to provide affordable treatment to the patient at the point-of-care and reduce the burden on the local healthcare system.

We set out to develop a set of recommendations for the management of patients with overweight and obesity that are relevant to the population of the UAE.

A multi-disciplinary panel of international and regional experts who treat patients with overweight and obesity was convened with the aim of developing consensus recommendations for the UAE. The panel considered a number of international guidelines on obesity as baseline references to identify the relevant recommendations. These were:

- American Association of Clinical Endocrinologists and American College of Endocrinology: Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. 2016 [15];

- Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults. 2016 [20];

- American College of Cardiology/American Heart Association/The Obesity Society (AHA/ACC/TOS): Guideline for the Management of Overweight and Obesity in Adults. 2014 [19].

Each member of the panel reviewed the references together with the research literature on obesity in the region. Based on their clinical experience, they proposed recommendations, which suited the local environment and aggregated them to form a set of practice recommendations. The panel held a second meeting to review and streamline these recommendations in its entirety for relevance, coherence and usability in the local context. The recommendations were circulated to the practicing family medicine community, namely the Emirates Medical Association and Family Medicine Society for their endorsement. The society has given their approval and support for our consensus recommendations for overweight and obesity management.

(1) The BMI should be used initially to confirm the presence of an excessive degree of adiposity, taking into consideration the ethnicity of the patient. Adults should be screened annually using the BMI measurement.

The BMI is a simple and widely used method for estimating body fat mass. In most populations, a cut-off point of ≥25 kg/m² is used to initiate further evaluation of overweight or obesity [15,21] (table 1 [15,22]). The BMI cut-offs vary in individuals of different ethnicities [15], e.g., a BMI of ≥23 kg/m² and ≥27.5 kg/m² for overweight and obesity respectively should be used for screening for excess adiposity in South Asian, Southeast Asian and East Asian adults. With the highest net migration rates in the world, 88.4% of the population of the UAE were migrants, mostly from South Asia (58%), followed by other parts of Asia (17%) and the West (9%) [10].

The BMI is mostly a linear measure of the weight, which continues to grow till an individual is in his fifties, but his height remained relatively stable after his twenties [23]. Hence, clinical evaluation and judgement must be used when BMI is employed as an anthropometric indicator of excess adiposity [24]. Physicians should use the BMI alongside other indicators if the BMI and physical examination results require further evaluation. However, some indicators, e.g. bioelectric impedance, air/water displacement plethysmography or dual-energy X-ray absorptiometry, are limited, costly or not available in clinics; and their outcomes data are not validated for cut-off points [15].

(2) The waist circumference (WC) measurement is recommended as a simple and complementary measure of excess visceral fat, taking into consideration the ethnicity and sex of the patient. ( table 1 [15,22])

(3) For patients with obesity, additional assessment of co-morbidities related to obesity is recommended.

Morbid obesity is associated with many diseases, and these affect essentially every organ system in the body (table 2[25,26,27,28,29]).

(4) A multi-disciplinary team approach to the treatment of obesity is recommended [30].

The team members would have a number of expertise, i.e. dietitian, health educator, physical activity coach, exercise trainer, clinical psychologist, psychiatrist and physician. Effective obesity management needs the close partnership of a committed health team and the motivated patient. Obesity treatment has wider benefits for the patient beyond weight loss: it improves his/her QoL and general health and reduces the risk of obesity-related complications. Significant health benefits can be achieved even with a modest weight loss (5-10% of baseline weight), dietary modifications and increased physical activity [31].

(5) Obesity management should focus on body composition and not merely BMI targets.

Improving the body composition translates into better risk management, and controlling and treating co-morbidities can improve QoL and the well-being of the patient. Obesity management also reduces the need to treat co-morbidities through prescription drugs.

(6) A comprehensive lifestyle intervention, when delivered on-site with face-to-face contact on an average of one to two treatment sessions per month over a period of at least 6 months, produces greater weight loss relative to usual care [20].

(7) Obesity management should address the following: self-monitoring of caloric intake and physical activity, goal setting, stimulus control, non-food rewards and relapse prevention.

The optimal management of overweight and obesity requires achieving a state of negative energy balance in the patient through a comprehensive lifestyle intervention programme, which combines three principal components: reduced-calorie diet, increased physical activity and behavioural therapy. Combining these three components in an intervention produces greater weight loss as compared to the singular use of these same components.

(8) A comprehensive lifestyle intervention through diet, exercise and behavioural modifications is recommended for individuals with BMI≥ 25 kg/m².

This intervention should consist of:

Diet Therapy

A review of dietary patterns showed that a diet consisting of sweets, fatty foods, meat, dairy products and canned foods is predominant in the Middle East and North African countries [32]. Where the patient is prepared to make changes to his/her daily dietary intake, a registered dietitian/nutritionist can prescribe an individualised diet, taking into consideration his/her degree of overweight/obesity, preferences and health condition.

(9) The individualised diet should be designed to induce an energy deficit of approximately 500-750 kcal/day from the current daily calorie intake. This can be achieved by prescribing 1,200-1,500 kcal/day for women and 1,500-1,800 kcal/day for men. Changes should be adapted depending on the presence of co-morbidities and ability of the patient to follow the diet.

A dietary prescription targeting either the larger nutrient (i.e. energy and macronutrient) or dietary pattern-based changes has been shown to be efficacious at producing clinically meaningful weight loss [20] (table 3[33]).

Physical Activity

A medical evaluation of the physical fitness of the patient is important to ensure safety prior to a new exercise programme. It includes an assessment of current physical activity level, readiness, mobility and fitness and, if necessary, cardiac stress testing, pulmonary function test and musculoskeletal assessment. Tracking daily physical activity through an activity log, pedometer or training metrics is recommended as a tool to improve adherence to the physical activity plan. Greater time spent on sedentary behaviour (activities with very low level energy expenditure i.e. leisure, occupation, transportation and recreation) has been associated with increased risk of obesity despite having spent time performing moderate to vigorous physical activity [34]. Sedentary behaviour indirectly influences eating habits, and increased sedentary behaviour is reported to be one of the causes of the obesity epidemic in the UAE [35]. Conversely, an increase in physical activity may help reduce the calorie intake. Hence, a re-allocation of time spent on sedentary behaviour, particularly leisure screen time, such as watching television, computer and tablet use, to light physical activity can increase overall energy expenditure.

(10) Moderate-intensity activity for at least 150 min/week (or 30 min/day for most days of the week) is recommended. For weight maintenance, 200-300 min or more of physical activity per week is recommended, again, depending on its intensity, unless medically contraindicated.

Behavioural Therapy

(11) When addressing obesity issues in patients, it is important to have a thorough psychological assessment to identify factors that may hinder goals for weight loss.

Many patients have undergone such an assessment without any issues being highlighted; and they have achieved their weight loss goals with minimal, if any, psychological intervention. However, for others, such intervention may be needed as psychological factors may pose an actual risk to the weight loss plan.

The most common psychiatric disorders that may co-exist with obesity are: dysthymic disorder, major depressive disorder, generalized anxiety disorder and binge eating disorder [36,37,38]. Patients with a history of such disorders experience poor weight loss due to the nature of their psychiatric illness [39]. They are also susceptible to internalized weight bias and body shame [40,41]. Women who are obese tend to report higher body image dissatisfaction than those with a healthy weight, which exacerbates the depressive symptoms and decreases self-esteem [42,43]. Body shame can also affect the sexual function of these individuals even though the cause of the sexual dysfunction may be due to other issues such as depression [38]. Personality factors also contribute to mood symptoms and dysfunctional eating behaviours [44]. For example, neurotic personality traits are related to heightened concerns about body figure and contribute to inadequate coping habits. This results in binge eating driven by stress, and may increase depression and anxiety.

Patients with obesity often have psychiatric co-morbidities, e.g. substance-related disorders, physical abuse and suicidal ideations [45,46,47]. Substance-related disorders such as alcohol abuse pose a particular risk as they exacerbate the lack of coping skills [48] and control. It may impair judgement and result in a suicide attempt. A history of sexual abuse also affects weight loss [37] as patients use dysfunctional eating habits as a way of coping with the associated emotional distress. In addition, the extra body fat could act as a protective mechanism against further sexual abuse. Childhood experience of parental loss is also another factor that has been associated with metabolic syndrome [49].

(12) The use of psychological intervention, such as Cognitive Behaviour Therapy (CBT), can help to resolve many psychosocial issues related to obesity and motivate the patient to implement the necessary behavioural and dietary changes for weight loss.

The National Institute for Clinical Excellence has recommended CBT as the treatment of choice to reduce psychological symptoms that pose a risk to weight loss regimens [50]. CBT is also used to treat eating disorder symptoms in high-risk situations, such as in pre- and post-bariatric surgery. Table 4[51] shows some interventions derived from a CBT modality that may benefit individuals suffering from obesity with or without severe psychological symptoms. This is by no means an exhaustive list of what the treatment entails.

Psychologists using CBT for psychosocial issues have to tailor their treatment plans to include cultural aspects to ensure positive outcomes. The cultural norms underpinning CBT needs to be tailored to accommodate Middle Eastern cultural norms of eating, observing and acknowledging religious holidays during the treatment process [52]. In addition, methods of challenging cognitive distortions need to be culturally appropriate so as to not come off as offensive.

Pharmacotherapy

(13) Pharmacotherapy for the treatment of obesity may be considered in patients with a BMI > 30 kg/m² with no co-morbidities or BMI≥ 27 kg/m² with co-morbidities and used in addition to lifestyle intervention [53].

Weight loss medication should be prescribed in the long term as for treatment of any chronic condition as an adjunct to lifestyle modification. There is little evidence to demonstrate the health benefits of short-term treatment with pharmacotherapy [54]. However, if <5% weight loss is achieved after 12 weeks, medication should be withdrawn. For certain ethnicities, a lower BMI can be considered for pharmacotherapy. The available anti-obesity drugs are orlistat (Xenical®, Alli®) and liraglutide (3 mg, Saxenda®) (table 5).

Orlistat. Orlistat is a lipase inhibitor which inhibits the breakdown of triglycerides in the gut into free fatty acids and monoglycerides, thus reducing their absorption into the blood stream [53]. Clinical trials of this drug have shown a 4.0% weight loss at 1 year over placebo and 2.6% weight loss at 4 years as well as a reduced progression from impaired glucose tolerance to type 2 diabetes mellitus (T2DM) by 45% over 4 years [55].

Liraglutide. Liraglutide is an acylated human glucagon-like peptide-1 (GLP-1) analogue which stimulates insulin secretion [56]. It lowers body weight through loss of fat mass, with greater reductions in visceral fat compared to subcutaneous fat. It increases feelings of fullness and satiety, while lowering feelings of hunger and prospective food consumption, thereby reducing food intake.

The efficacy and safety of liraglutide in reducing weight has been evaluated in four randomized, double-blinded, placebo-controlled trials: SCALE 1 [57], SCALE 2 [58], SCALE 3 [59] and SCALE-Maintenance [60]. In SCALE-Obesity and pre-diabetes and SCALE-Diabetes, 67.5% and 50.4% respectively achieved ≥5% weight loss after 12 weeks (early responders). With continued treatment, 86.2% were expected to achieve a weight loss of ≥5% and 51%, ≥10% weight loss after 1 year of treatment. In SCALE-Sleep Apnoea, the improvement in apnoea/hypo-apnoea index in patients with obstructive sleep apnoea was greater for patients with liraglutide compared to placebo. In SCALE-Maintenance, more patients (81.4% vs. 48.9%) maintained their weight loss (prior to treatment) with liraglutide than with placebo [60]. Liraglutide also significantly improved glycaemic parameters across various sub-populations: normal-glycaemia, pre-diabetes and T2DM.

(14) The choice of weight loss medication should take into account contra-indications and safety profile, associated co-morbidities, efficacy, cost and availability. We have listed specific consideration for patients with certain co-morbidities and special circumstances ( table 6 [61,62,63,64,65,66,67,68]).

The use of pharmacotherapy for weight loss should also take into account:

- Pregnancy: Pharmacotherapy must not be used in pregnancy, and in breastfeeding women. Women of childbearing age, who are on pharmacotherapy, should be advised to use contraception.

- Post-bariatric surgery: Patient who have re-gained excess weight (>25% of weight loss), have not responded to intensive diet or exercise and cannot be considered for revisional surgery, may be considered for treatment with liraglutide post-surgery.

Bariatric Surgery

(15) Bariatric surgery should be considered for patients with a BMI≥ 40 kg/m² and no co-morbidities; or≥ 35 kg/m² with one or more co-morbidities and for whom the procedure would not be associated with excessive risk [69].

Patients with a BMI of 30-34.9 kg/m² with T2DM can be considered for bariatric surgery, although the evidence is limited [70]. For certain ethnicities, e.g. patients of Asian origin, lower BMI cut-off criteria can be considered [71]. Patients should undergo a pre-operative assessment of obesity-related complications, and the choice of bariatric surgery should be discussed with the surgeon, including the advantages and disadvantages of each procedure. Patients should be followed-up life-long for nutritional surveillance.

(16) Assessments for psychological stability should be undertaken for patients undergoing bariatric surgery.

Assessing psychological stability of the patient to identify aspects that needed to be addressed and resolved in order for the surgery to be successful would also aid weight loss success post-surgery. For example, the American Society for Metabolic and Bariatric Surgery have made available an excellent psychological assessment template which takes into account the reasons for seeking surgery, expectation and understanding of surgery options, history of weight management, eating behaviour and diet history, risk-taking behaviour, physical activity, coping skills, cognitive functioning and psychopathology [72]. If issues are uncovered, they can be addressed and resolved through psychotherapy.

(17) Patients should maintain their weight loss and be encouraged to keep in contact with a nutritionist to ensure that their dietary plan remains suitable to their evolving needs.

Patients typically regain 35-40% of their lost weight in the year following the weight loss programme [73]. Maintaining long-term weight loss takes a different approach than losing the weight. Besides having information on nutritional needs, healthy and balanced nutrition and menu preparation, it is important to maintain a consistent eating pattern and, if a setback occurs with the diet (e.g. during vacation or on holidays), to get back on track as soon as possible.

(18) Physical activity is essential to achieving long-term weight loss, and as a rule patients should perform moderate intensity physical activity for at least 200-300 min/week and weigh themselves regularly (daily) [30].

Patients should have a plan of action especially when they see themselves regaining weight. They are encouraged to meet regularly with physical health advisers so that they can sustain their personalized fitness regimes.

(19) Patients should be trained in relaxation methods and meditation with positive thoughts to address emotional fluctuations rather than give in to compulsive eating behaviours.

For emotional eaters, counselling to help patients learn new ways to handle their emotions: e.g. rather than turning to food, instead go for an activity that they enjoy or connect with a friend. Stress confrontation is used to identify and recognise emotional triggers that may contribute to compulsive eating behaviours.

The use of weight loss medication is encouraged to promote long-term weight maintenance, ameliorate co-morbidities and increase adherence to behavioural changes. This can improve the physical function and allow for greater physical activity [15].

These consensus recommendations for managing overweight and obesity are developed in response to the high prevalence of obesity and lack of local clinical recommendations in the UAE. A summary of these recommendations is provided (fig. 1), and the accompanying algorithm is shown in figure 2. Overweight and obesity are chronic conditions that require comprehensive lifestyle modification [73], augmented by pharmacotherapy and/or surgery [60]. Besides reducing weight in subjects who are obese, it is also important to maintain the weight loss achieved. A multi-disciplinary approach is required to implement these strategies, control the associated co-morbidities and long-term patient follow-up to ensure success.

All authors were involved in conceptualising the study design, drafting their respective sections, proposing the recommendations and revising it critically for important intellectual content, and all authors approved the final version submitted for publication. Drs. Fargaly and Abusnana co-chaired the panel meetings.

We would like to thank the Emirates Medical Association and Family Medicine Society for reviewing and endorsing the recommendations in our manuscript. Their support and endorsement will greatly facilitate the implementation of these recommendations in clinical practice. Novo Nordisk provided support for the panel meetings. Technical editorial and manuscript drafting assistance was provided by Sen-Kwan Tay of Tech Observer Asia-Pacific Pte Ltd and supported by Novo Nordisk.

Drs. Kaddaha, McGowan and Nawar are on the advisory board of Novo Nordisk.