INTRODUCTION Obesity is a chronic relapsing progressive disease defined by abnormal or excessive adiposity that may impair health and is staged based on the severity of the complications due to that adiposity.1-3 The obesity epidemic adversely affects the active duty military population with a prevalence of 13-18% (based on body mass index [BMI] >30 kg/m2 underestimating cardiometabolic consequence of abdominal obesity and not accounting for ethnic differences).4-6 Retirees' and dependents' 30% prevalence7 approaches the general community in the US8-9 and similarly around the world (including "overweight" classified as BMI >25 kg/m2).10 Obesity prevalence in the military veteran population has also risen coinciding with the general population including significant disparities.11-12 The prevalence is unfortunately similar in military recruits.13 These trends pose serious health risks to the active duty and veteran population with very high morbidity and mortality associated with it.14-17 Data from three cycles of the Millennium Cohort Study documented doubling of obesity rates per BMI in active duty members (10-20%) and veterans (14-32%) correlated with statistically significant higher rates of complications including hypertension, type 2 diabetes (T2DM), obstructive sleep apnea, depression, and post-traumatic stress disorder.18 This unfavorably impacts readiness and comprises the whole military family leading to yearnings to develop multidisciplinary strategies to combat the problem.19-20 There is also understandable substantial financial strain put upon the Department of Defense (DoD) health care system.21 COMPLEXITY OF OBESITY AND APPROPRIATE MEDICAL TREATMENT Obesity is a complex disease with an intricate and diverse spectrum of etiologies.OBESITY IS COSTLY The financial cost of obesity and its complications continue to rise around the world along with the prevalence.27-28 A retrospective evaluation of TRICARE beneficiaries under the age of 65 yr using cost-of-disease modeling suggested that the DoD spends an estimated $1.1 billion per year on medical care associated with excess weight and obesity with more related to nonmedical costs from absenteeism and decreased productivity.29 The Veterans Affairs Medical Centers additionally take the brunt of veterans with obesity as health care expenditure includes billions of dollars on complications of obesity like T2DM.30 PHARMACOTHERAPY Despite the increased morbidity and mortality of obesity, there have been very few effective pharmaceutical options available for obesity treatment until 2012, targeting some of those complicated neuroendocrine pathways.Topiramate combined with phentermine in extended release formulation (phen/top ER) is approved for chronic treatment of obesity and has been shown to be superior for mean weight loss when compared with the individual components.31 The placebosubtracted average weight loss in phase 3 clinical trials for phentermine/topiramate (phen/top) ER ranged about 7-9% and the results were maintained for the completers who extended to 2 yr.32-34 The combination has been shown to delay the progression to T2DM in those at high risk (metabolic syndrome or pre-diabetes)35 and in a pooled analysis of Phase III Clinical Trials Assessing Phen/Top ER, higher Cardiometabolic Disease Staging score predicted effectiveness of weight Loss therapy to prevent T2DM.36 A phase 2 trial of high-dose phen/top ER in subjects with T2DM and baseline Hemoglobin A1c (HbAlc) of 8.7% resulted in an average of 7% more weight loss than placebo with corresponding improvement of HbA1c of 1.6% compared with 1.2%.37 This improvement was associated with better blood pressure and lipids along with fewer glycemic medication requirements.Despite concerns of adverse serotonin effects on cardiac valves, no concerning valvulopathy was found in trials of lorcaserin including those with pre-existing valvulopathy.54 A cardiovascular outcome trial involving naltrexone/bupropion ER was conducted with early reassuring statistics but was terminated early due to leaked study information compromising the outcomes and the resulting data remain unclear.55 Liraglutide was shown to have cardiovascular outcome benefits at the diabetes treatment dose of 1.8 mg daily compared with placebo or usual targeted care in those with T2DM and established atherosclerotic cardiovascular disease.56 Although generally well tolerated, considerations for the burdens of active duty personnel must be paid special attention.

Military medicine

Naltrexone - therapeutic use; Obesity - drug therapy; Humans; Appetite Depressants - therapeutic use; Military Personnel - statistics & numerical data; Benzazepines - therapeutic use; Drug Therapy - methods; Alcohol Deterrents - therapeutic use; Liraglutide - therapeutic use; Phentermine - therapeutic use; Retrospective Studies; Drug Therapy - statistics & numerical data; Incretins - therapeutic use; Cohort Studies; Appetite; Health care; Obesity; Veterans; Mortality; Clinical trials; Pharmacology; Body mass index; Weight control; Post traumatic stress disorder; Population; Diabetes; Clinical medicine; Drug therapy; Index Medicus

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