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Obesity in Adults: Treatment and Management Gary D. Foster, PhD Clinical Director, Weight and Eating Disorders Program Assistant Professor, Department of Psychiatry University of Pennsylvania School of Medicine © 2000 University of Pennsylvania School of Medicine Objectives Describe the efficacy of the following for the treatment of obesity: Behavioral methods Pharmacological therapy Surgical approaches Identify the pros and cons of self-help diets for the treatment of obesity. Review new guidelines for successful outcomes in obesity treatment. © 2000 University of Pennsylvania School of Medicine Treatment of Obesity Behavioral Pharmacological Surgical Self help programs and books © 2000 University of Pennsylvania School of Medicine Behavioral Treatment Philosophy Consists of a set of principles and techniques to modify eating and activity habits. Emphasizes small and sustainable changes. © 2000 University of Pennsylvania School of Medicine Behavioral Treatment Methods Identifying Patterns Buy chips Leaves chips on table Come home from work, tired and hungry See kids eating chips Eat several handfuls of chips standing up Feel guilty Finish bag of chips © 2000 University of Pennsylvania School of Medicine Behavioral Treatment Methods Self-monitoring Recording food intake/evaluating nutrients Recording physical activity Stimulus control techniques Time Place Activity Sight/smell Emotions © 2000 University of Pennsylvania School of Medicine Behavioral Treatment Methods Rationale for Increasing Physical Activity Associated with significant health benefits. Single best predictor of weight maintenance. Not associated with short-term weight loss. © 2000 University of Pennsylvania School of Medicine Behavioral Treatment Methods Increasing Physical Activity Identify barriers Lack of time Lack of motivation Increased safety concerns Prescribe small changes Take the stairs Gardening Walking during work © 2000 University of Pennsylvania School of Medicine Behavioral Treatment Results 10% reduction over 20 to 24 weeks 33% regain at one year More weight regained over time © 2000 University of Pennsylvania School of Medicine Improving Weight-loss Maintenance Continued care Sustaining dietary changes Exercise Pharmacotherapy © 2000 University of Pennsylvania School of Medicine Treatment of Obesity Pharmacological Therapy Pharmacological interventions to facilitate weight loss and behavior change include: Enhancing satiety Decreasing fat absorption Increasing energy expenditure Decrease appetite © 2000 University of Pennsylvania School of Medicine Sibutramine (Meridia) Mechanism of Action Serotonin and norepinephrine re-uptake inhibitor (SNRI). Animal research data shows drug reduces body weight by: Decreasing food intake in rats Stimulates thermogenesis in rats © 2000 University of Pennsylvania School of Medicine Sibutramine (Meridia) Summary of Research Findings 6% to 8% weight loss with 10 to 15 mg/day. 2% weight loss with placebo. Published data available up to one year. © 2000 University of Pennsylvania School of Medicine Sibutramine (Meridia) Summary of Reported Adverse Event Percent (%) of Patients Adverse Event Placebo (n = 884) Sibutramine (n=2068) Dry mouth 4 17 Anorexia 4 13 Constipation 6 12 Insomnia 5 11 Appetite increase 3 9 Dizziness 4 7 Nausea 3 6 Package insert data, Sibutramine, 1998. © 2000 University of Pennsylvania School of Medicine Sibutramine (Meridia) Prescribing Information For patients with BMI > 30 or > 27 in the presence of risk factors. 5 to 15 mg per day. Not for patients on SSRIs (e.g. Paxil, Zoloft, Prozac) Not for patients with poorly controlled hypertension, history of coronary artery disease, CHF, arrhythmia or stroke. Regular BP and heart rate monitoring required. © 2000 University of Pennsylvania School of Medicine Orlistat (Xenical): Mechanism of Action Activity occurs in the stomach and small intestine. Inhibits gastric and pancreatic lipases. 30% of ingested fat is unabsorbed and excreted. Minimal systemic absorption. Low-fat diet ( 30%) required to minimize side effects. © 2000 University of Pennsylvania School of Medicine Orlistat (Xenical) Summary of Research Findings 0 0 Placebo Orlistat % Wt Loss -2 -4 -4.6 -6 -6.1 -7.8 -8 -10 -10.2 -12 0 1 2 Time (years) Sjostrom L et al. Lancet 1998;352:167-172. © 2000 University of Pennsylvania School of Medicine Orlistat (Xenical) Summary of Reported Adverse Events Adverse Events Overall Incidence (% of Patients) Oily spotting 26.6 Flatus with discharge 23.9 Fecal urgency 22.1 Oily stool 20.0 Oily evacuation 11.9 Increased defecation 10.8 Fecal incontinence 7.7 Package insert data, Orlistat, 1998. © 2000 University of Pennsylvania School of Medicine Orlistat (Xenical) Prescribing Information 120 mg TID with meals containing fat. Patients should be on a nutritionally balanced, low-fat diet (< 30%) to minimize side effects. Prescribe multivitamin to be taken at least two hours before or after the medication. Orlistat is contraindicated for pregnant or lactating women, and those with chronic malabsorption syndromes or cholestasis. © 2000 University of Pennsylvania School of Medicine Chronic Pharmacological Treatment and Challenges Similar to pharmacotherapy of other chronic conditions. Consistent weight gain seen when medications are discontinued. Requires intensive risk/benefit analysis and careful patient selection. Safe and effective medications. © 2000 University of Pennsylvania School of Medicine Surgical Treatment of Obesity Patient selection criteria BMI > 40 or > 35 for those with weight related co-morbidities. History of failed conservative weight loss approaches. No substance abuse and/or psychiatric disorders. Surgical options Vertical banded gastroplasty (VBG) Gastric bypass (GBP) Outcomes Weight loss is 25% to 35% of initial weight. Weight loss is generally well maintained. Significant improvement in co-morbidities. © 2000 University of Pennsylvania School of Medicine Surgical Treatment of Obesity Vertical Banded Gastroplasty (VBG) Staple Line Formation of small proximal gastric pouch. Restricts amount of food without bypassing the gut. Delays gastric emptying. Creates feeling of early satiety. Pouch Band Fundus © 2000 University of Pennsylvania School of Medicine Surgical Treatment of Obesity Gastric Bypass Formation of 20-30 ml proximal gastric pouch. Delays gastric emptying. Interferes with absorption of nutrients. May induce dumping syndrome after high carbohydrate meal. Staple Line Pouch Fundus Jejunum © 2000 University of Pennsylvania School of Medicine Treatment of Obesity Popular Weight Loss Diets Low-calorie diets Calorie deficit allows for 1 to 2 pound weight loss/week Nutritionally balanced food plan (15% protein, 30% fat, 55% carbohydrate) Weight Watchers, Jenny Craig High protein, low carbohydrate diets Emphasis can vary between unrestricted sources of protein and consumption of only lean sources (chicken, fish). Dr. Atkins’ New Diet Revolution, The Zone, Sugar Busters. © 2000 University of Pennsylvania School of Medicine Treatment of Obesity Popular Weight Loss Diets Low-calorie diets Weight Watchers Jenny Craig Low-carbohydrate diets Dr. Atkins’ New Diet Revolution The Zone Sugar Busters © 2000 University of Pennsylvania School of Medicine Low-Calorie Diets Usually provide a total calorie deficit to allow for 1 to 1 1/2 pounds of weight loss per week. Rely on use of fat-free and low-fat foods. Balanced nutritional food plan. (15% protein, 30% fat, 55% carbohydrate) Mulitvitamin/mineral supplement recommended. © 2000 University of Pennsylvania School of Medicine Commercial Programs Weight Watchers Traditional program includes a balanced low calorie diet containing 1200 calories per day for women; 1800 calories for men. Offers a flexible 1-2-3 program which enables you to eat whatever you want using a point system which are determined based on your weight loss goals. Priced reasonably; approximately $12.00 per visit. Weekly “weigh-ins” and purchasing your own food. Group meetings lead by successful program graduates which provide support and advice on behavior modification, exercise, and nutrition. © 2000 University of Pennsylvania School of Medicine Commercial Programs Jenny Craig Offers several programs to meet individual needs Provides weekly planned menus which are nutritionally balanced Menus feature Jenny Craig packaged foods which can cost approximately $65 - $75 per week Offers convenience for the person who does not cook Calorie levels range from 1000 - 2300 calories/day Provides basic strategies for managing stress and physical activity Staff not medically trained © 2000 University of Pennsylvania School of Medicine Dr Atkins’ Diet Book • High protein diet. • To identify methods to assess the nutritional status of healthy patients as well as those with acute or chronic illness. • To identify risk factors and usual physical findings associated with malnutrition and determine who would benefit from additional nutrition counseling. © 2000 University of Pennsylvania School of Medicine Atkins Diet: The Rules of the Induction Diet (14 days) • Diet consists of pure proteins and fat with < 20 grams carbohydrates per day. • Sample menu: Breakfast: Ham, cheese, mushroom omelet with bacon or smoked fish with cream cheese. Lunch: Chef salad with ham, chicken, cheese, eggs, creamy Italian dressing or bacon cheeseburger- no bun. Dinner: rack of lamb, salmon or chicken and salad. Dessert: assorted cheeses or diet Jello with heavy cream. © 2000 University of Pennsylvania School of Medicine Biochemical Aspects of the Atkin’s Diet • No more than 20 grams of carbohydrates/day so that insulin levels are decreased. • Low insulin/glucagon (IG) ratio results in fatty acid oxidation and gluconeogenesis for energy. • Goal is to achieve ketosis/lipolysis. • High protein diet needed to preserve lean body mass (muscle protein) however there is always a state of low protein synthesis due to low IG ratio. © 2000 University of Pennsylvania School of Medicine Metabolic Effects of Low Carbohydrate Diets Significant reduction in caloric intake. Significant reduction in B vitamins and fiber intake. Increased ketone formation if severe CHO restriction. High saturated fat diet clearly shown to increase serum LDL levels and risk of CVD. No long-term studies on weight change (-/+) or effects on serum glucose or LDL levels. © 2000 University of Pennsylvania School of Medicine Zone Diet Book by Barry Zears, PhD • Ideal ratio of carbohydrate, fat, and protein is 40, 30, 30, respectively. • All meals and snacks should be composed of this nutrient ratio. • Can purchase meals, beverages, snack bars providing correct nutrient ratio. • Based on the fact that carbohydrates stimulate insulin secretion which in turn causes excess calories to be converted to fat. • Emphasizes low fat proteins such as chicken and fish. • Avoidance of caffeine is recommended. • Calculating correct amount of protein, fat, and carbohydrate per meal can be time consuming. © 2000 University of Pennsylvania School of Medicine Sugar Busters Drs. Rachael and Richard Heller • Follows the basic diet plan of Dr. Atkins’ high protein, low carbohydrate diet, emphasizing lean meats. • Focus is on avoiding refined carbohydrates such as sugar and white rice. • Diet allows one reward meal each day in which carbohydrates are permitted. • Avoids food eaten in combination (i.e. fruits should not be eaten with meat dishes). © 2000 University of Pennsylvania School of Medicine Improving Weight-loss Maintenance Continued care Exercise Pharmacotherapy Other © 2000 University of Pennsylvania School of Medicine Weight Change: Former Criteria for Success Reduction to ideal body weight. Reduction of 50% of excess weight. Reduction to upper limit of “normal” body fat © 2000 University of Pennsylvania School of Medicine Reasons for Abandoning Ideal Weight with Significantly Overweight People Most cannot achieve ideal weight, even with most aggressive approaches. Most cannot maintain losses >15% of initial body weight without surgery. Losses of 5% to 10% of body weight are associated with significant health improvements. © 2000 University of Pennsylvania School of Medicine Weight Change New Criteria for Success According to the Institute of Medicine’s report, Weighing the Options: Successful long-term weight control by our definition means losing at least 5% of body weight and keeping it below our definition of significant weight loss for at least one year. Weight loss of only 5% to 10% of body weight may improve many of the problems associated with overweight, such as high blood pressure and diabetes. Thomas P (ed). Weighing the Options. Washington, DC: IOM, National Academy Press,1995. © 2000 University of Pennsylvania School of Medicine What Is A Reasonable Weight Loss ? Patients’ Expectations and Evaluations of Obesity Treatment and Outcome Study design 60 obese women, age 40 + 8.7 yrs. BMI 36.3 + 4.3 kg/m2 Subjects questioned about their goal weight Dream weight Happy weight Acceptable weight Disappointed weight Foster GD, et al. J Consult Clin Psychol 1997;65:79-85. © 2000 University of Pennsylvania School of Medicine Results Defined Weights % Reduction Dream 38% Happy 31% Acceptable 25% Disappointed 17% Foster GD, et al. J Consult Clin Psychol 1997;65:79-85. © 2000 University of Pennsylvania School of Medicine Percent Achieving Defined Weight at Week 48 (n=45) Happy 9% Dream = 0% Acceptable 24% Weight loss: 16.3 ± 7.2 kg Disappointed 20% Did not Reach Disappointed Weight 47% Foster GD, et al. J Consult Clin Psychol 1997;65:79-85. © 2000 University of Pennsylvania School of Medicine Helping Patients Accepts More Modest Weight Loss Be clear about what treatment can and cannot do. Discuss biological limits. Focus on non-weight outcomes. Be empathic about dissatisfaction with weight and shape. © 2000 University of Pennsylvania School of Medicine