Download 1 - RCRMC Family Medicine Residency

How to Lose Weight
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How many more calories a day
does the average American eat
today compared to someone in
1970
A. 200
B. 300
C. 400
D. 500
E. 523
Answer
• E. 523
What has changed to increase the
calories?
Answer
• Larger portions
• Increased processed fats and sugars
Can Physicians make
interventions that are meaningful
for weight loss, control of BP, BS
and Cholesterol in routine
clinical practice?
Reducing Blood Pressure Levels Effectively in Practice
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Two interventions each helped to modify this cardiovascular risk factor
successfully, but staffing such programs would be costly.
Practice guidelines for the prevention of cardiovascular disease identify clear
targets for risk-factor modification but often say little about the difficult
objective of actually achieving them. Now, we have data on two strategies
specifically designed to help patients with uncontrolled CVD risk factors reach
their prevention goals.
In one study from a California county health system, researchers enrolled 419
low-income patients (mean age, 55; 66% women; 85% nonwhite) who had at
least moderately uncontrolled, modifiable CVD risk factors. Participants (19%
with established CVD, 63% with diabetes) were randomized to receive usual
care or one-on-one nurse- and dietician-led case management that emphasized
behavior modification and medical management. At 15 months, the mean
Framingham risk score (FRS) had declined significantly more in the casemanagement group (by 0.92 points to 7.80) than in the usual-care group (by
0.19 points to 8.93). FRS changes were consistent across sex and racial
subgroups. Most of the advantage of case management was attributable to
significant declines in systolic and diastolic blood pressures. Using prior data
on the association between risk-factor modification and outcomes, the
researchers estimated that the case-management program would prevent 1
adverse cardiovascular event in every 200 patients.
Reducing Blood Pressure Levels Effectively in Practice
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In the other study, six family medicine clinics in Iowa (serving 402 patients
with poorly controlled hypertension) were randomized to (1) an intervention in
which pharmacists monitored patients and offered treating physicians
guideline-based medication-intensification recommendations for lowering
blood pressure or (2) no intervention. Because clinics — not patients — were
randomized, baseline characteristics differed significantly in some respects; for
example, patients at the control clinics had lower initial blood pressures and
were more likely than intervention patients to have no insurance and to have
diabetes. The researchers adjusted for such differences and found that,
compared with patients at the control clinics, those at the intervention clinics
had significantly lower systolic blood pressure at 6 months (about 12 mm Hg
lower, on average, despite the baseline disadvantage) and were significantly
more likely to achieve blood pressure control (odds ratios: 3.2 in the overall
cohort and 4.7 among diabetic patients).
Comment: Each of these studies identified an intervention that reduced blood
pressure effectively among patients with uncontrolled risk factors in clinical
practice. However, both programs require substantial staffing, which is costly.
Without meaningful financial incentives for achieving risk-factor modification
in community practice, implementing such interventions in the broader
population would likely be difficult, despite their effectiveness.
— Frederick A. Masoudi, MD, MSPH
Conducting brief interventions
• workbook or information sheet
• advantages of workbook—gives patient
something to take home, think about, and
refer to
• Clinician sits beside patient while
discussing contents of workbook, or
information sheet.
• It conveys sense of teamwork; because
patient does not have to look at clinician, he
or she may experience less fear of stigma
and find communication easier
Identify goals
• what does patient want to achieve over next 3 mo
to 1 yr?
• include goals about physical health, activities and
hobbies, and relationships
• So you would like to be able to walk one mile
with your gramd kids. Lets start with the chair
exercise program, stand and walk in place 15
seconds 100 times a day, and work up to that mile
• You would like to lose 20 pounds so lets start by
eating breakfast and reducing some carbohydrates
and reducing high calorie foods from your diet
Screening: summary of
patient’s health habits
• Ask questions about exercise, smoking,
nutrition, alcohol use, and (particularly in
older adults) medications
• How much do you exercise?
• What do you eat?
• Do you eat breakfast?
• Do you drink fruit juices, soda, alcohol?
• Ask the patient which health habits he or
she wants help with?
Discussion
• Address patient’s health concerns, but allow
redirection of conversation to weight loss
• Ask patient for his or her definition of a good
weight
• Educate the patient about accepted definitions by
doing BMI, body fat, waist circumference, and fat
calipers
• Inquire about what patient likes about eating (eg,
taste, greater comfort in social situations, reduced
stress and/or loneliness);
• Gently inform patient of negative consequences
obesity
• Discuss reasons for cutting down on consumption
Weight loss agreement
• The clinician makes suggestion of goal for
reducing weight
• You may need to negotiate with patient
about frequency, timing, and/or quantity of
weight loss and appointments
• The patient may not agree, but clinician
records recommendations and both parties
sign agreement
Understanding Hunger
To understand how emotional or mindless eating work, it's important to
know about the two types of hunger:
• real hunger
– grows gradually
– you'll eat anything
– can wait
– you stop when you're full
– you feel good after eating
– you gain energy
• emotional hunger
– hits suddenly
– you crave a specific food (usually high in fat)
– needs to be satisfied instantly
– you can't stop, period
– you feel guilty after eating
– you gain weight
Get the Patient into a different
Mindset
Traditional diets are a short-term fix to a longterm problem.
But the key to losing weight and keeping it off
has to be learned over time.
Over time, healthy eating will become habit.
Over time, you'll become more active, and
more content.
Over time, your life can get more satisfying—
and stay that way.
How to start
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Plan
Today decide what you will eat tomorrow.
Write it down and keep it in your pocket.
Here are three winning tips to get you
started.
How to start
• Don't let yourself go hungry
• Eat breakfast in the morning. You need high fiber
and protein to fill you up and make you less
hungry.
• Reduce carbohydrates except for a small serving
of dark chocolate in the morning, to give you
some immediate energy. Dark Chocolate has allot
of antioxidants that are good for you
• Try eating 3 main meals and healthy snacks in
between. This keeps you feeling satisfied while
avoiding cravings from your external hunger.
• Take time to plan and schedule tomorrow's
healthy meals—and stick to your plan.
How to get started
• Take 15 minute breaks
• Satiety—that's the feeling of being full.
Unfortunately there's about a 15-minute lag
between when you're stomach gets this
message and when you're brain gets it.
Eating more slowly can give your stomach
the quarter of an hour it needs to relay your
fullness status to your brain. Taking 15 can
help you avoid overeating. Find a partner
and make lunch and snacks at work a social
occasion. A little chat can make that 15
minutes feel like nothing.
How to get started
• Arm yourself with healthy snacks
Healthy snacks are a great way to stay satisfied
between meals and help make sure that you're
eating at least every 4 hours. Low-fat foods, like
fresh fruit, fat-free pudding cups, and low-fat
crackers, will keep you from getting too hungry
and grabbing the first thing you see. If you're
running around or working, keep some unsalted
pretzels in your bag. Have some hummus in your
work fridge and bring in some carrot and celery
sticks. Give yourself options when you're working
or on the move.
We won't sugar coat it. It's hard to eat healthy when you eat out. Restauran
meals usually contain more salt and fat and sugar than the dishes you whip
up at home. But with a little insight, you can hit your favorite restaurants
and still eat for optimum health.
Look for the low-fat proteins. Favor low-fat food prep techniques like
grilling. Watch out for those hidden calories-they're lurking in mayo and in
cream-based sauces. And remember, restaurant portions are generally way
more food than you need.
Go for chicken and seafood-protein options with less saturated fat than red
meat
Ask for meat and fish to be grilled, definitely not fried
Make sure there are veggies on your plate
Go for tomato-based sauces as opposed to cream-based
Always order dressings on the side-so you stay in control, and see if there
are lower-fat alternatives available
Try mustard instead of mayo, or choose a low-fat mayo
Forget that guilt-trip your parents gave you about always cleaning your
plate. Leaving food on your plate is a victory, proof of your new-found
Restaurant dinning tactics
• Stick to the appetizer and salad sections of the menu. Make
veggie-based choices for your appetizers. Make the main
course a Cobb or grilled chicken salads. Avoid the fried
chicken-strip salad and the Caesar salad.
• Dip into salad dressing. Go for a fat-free or low-fat
dressing. Dip your fork into the dressing, and then the
salad-you'll still get the flavor you want, but not more than
you need.
• You're special-so don't be shy about special orders. Most
restaurants are happy to modify meals to make customers
happy. Don't be afraid to ask the server how a dish is
prepared. If the dish is high in fat, ask if they can cook the
steak without butter, or grill or broil the fish instead of
frying. Even if you have to pay a little extra, the benefits to
your health are worth the small difference in price.
Restaurant dinning tactics
• Always be the first to order. Listening to the choices that friends or
family make at restaurants may influence your decision, even if you
have the best intentions. Eliminate the temptation by being the first to
order. When you're done eating, ask for your plate to be removed, so
you don't pick.
• Order à la carte This is especially true for fast-food restaurants. For
instance, the regular price for a sandwich might be $3, but for $4 you
also get chips and a soda. You might think you saved money, but you
actually spent more, got food you didn't want, and extra calories you
don't need.
• Split meals with a friend. Many restaurant portions are enough for two
people to split-and making a meal a social occasion has the added
benefit of forcing you to eat more slowly, so you sense satiety before
you've overeaten. If you're on your own, get a doggie bag and place
half your meal in it when it is served. It will keep that portion out of
sight and make a great lunch the next day.
Restaurant dinning tactics
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Be vigilant-hidden calories can be anywhere. Many dishes contain more calories than you realize
because of breading, sauces, or frying. This is how hidden fat sneaks into your meal. If you aren't
certain what a meal comes with or how it is prepared, ask your server. If you see any of the following
words describing a menu item, your stealth calorie detector should start tingling.Au gratin
Parmesan
Cheese sauce
Scalloped
Rich
Creamy, cream sauce
Buttered, buttery
Pastry
Breaded
Fried
Seasoned
Southern-style
Limit your alcohol. Alcohol is loaded with empty calories and it's all too easy to consume too much
alcohol without thinking about it, especially when you're with friends, having a Friday lunch, or
blowing off steam after work. Stick to white wines and the lighter versions of your favorite lager
beer. Sparkling water with lime or lemon is a refreshing, healthful alternative.
Ban the breadbasket. Whether it's dinner rolls, breadsticks, or tortilla chips, ask the server not to
bring it, or push it out of immediate reach. The starch basket tends to contain a lot of refined whiteflour products-lots of calories, minimal nutritional value.
Restaurant dinning tactics
• Skip dessert or have fruit-based desserts. Resist dessert if you're full
and not internally hungry. Remind yourself you can have something
later, when your body-not your psyche-is hungry again. Otherwise,
consider good-tasting but low-calorie choices like sorbet, low-fat or
fat-free frozen yogurt, angel food cake, or fresh fruit.
• Ask for backup. Let your buddies in on your program. True friends
will embrace an opportunity to help you. Ask them to keep the starch
basket on their side of the table, and not egg you on to that rich dessert
or second glass of Pinot grigio.
• Monitor your emotions. Slipping up is human, but you are less likely
to do it if you ask yourself "What do I want from this meal?" before
you enter the restaurant. If you do overeat, don't kick yourself. You're
human and you've embraced a long term-based positive program for
change. And, if you do decide to eat more, don't consider it a
catastrophe later. Review your past Steps (accomplishments), chat with
peers, or write in your journal to get back on track. One meal will not
make or break your program for healthier change.
Ten Myths About Obesity
Tobacco-related mortality
• data from Centers for Disease Control and
Prevention (CDC) showed that obesityrelated mortality growing at rate that would
soon overtake tobacco- related mortality
• methodology of data analysis criticized
• findings refuted
• tobacco remains leading cause of
preventable death in United States (obesity
second)
Childhood obesity: only partially
true that epidemic slowing down
• overweight in children defined as body
mass index (BMI) >85th percentile of
average weight for age group,
• based on cohort from 1960s and 1970s
(obese >95th percentile,
• severely obese >97th percentile)
• downward trend
• in childhood obesity among whites, but
increase seen in black and Latino
communities
Effect of weight on mortality
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BMI—underweight <18.5;
normal 18.5 to 25
overweight 25 to 30
obesity class I 30 to 35
obesity class II 35 to 40
obesity class III (extreme obesity) >40
National Health and Nutrition Examination Survey (NHANES) data—3 studies over 20
yr; slightly higher mortality of underweight category largely due to smoking (most
smokers thinner)
obesity (all classes) associated with excess mortality, but risk not dramatically higher
(relative risk [RR] 1.8)
overweight (BMI 25-30) not associated with excess mortality
in blacks BMIs of 27 to 30 associated with normal outcomes
while in Asians, BMIs as low as 23 may be associated with excess mortality
clinician’s role—determine whether patient has type of overweight associated with
adverse outcomes
look for metabolic syndrome (measure waist circumference, blood pressure, lipids)
take family history
current data—risk attributable to obesity decreasing over time, possibly because of
better management of related conditions
Overweight and Mortality in
an Older Population
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Above-normal BMI was somewhat protective in women.
Are overweight elders at elevated risk for death, compared with those whose weight is
normal? To find out, Israeli researchers identified about 2400 Jerusalem elders (age
range, 70–85 at baseline) and followed them for 3 to 18 years. Normal, overweight, and
obese were defined as body-mass index (BMI) of 18 to 24.9 kg/m2, 25 to 29.9, and 30,
respectively.
In analyses that were adjusted for potentially confounding factors that could predispose
to death, women who were overweight or obese had significantly lower mortality than
women with normal BMIs. In men, mortality was similar in all three BMI categories. In
additional analyses, the researchers omitted deaths that occurred during the first several
years of follow-up, to account for "reverse causality" (which would occur if lowerweight people had diseases at baseline that would cause death within a relatively short
time); this maneuver did not affect the results.
Comment: In this study of an older population, being overweight or mildly obese was
not associated with shorter survival. Indeed, having above-normal BMI was somewhat
protective in women. These results should not be used to justify weight gain as people
age; rather, the implication is that overweight people in their 70s and 80s should not
necessarily be pushed to lose weight if they are otherwise active and well. These results
do not apply to severe obesity, which was not well-represented in this cohort.
— Allan S. Brett, MD
Published in Journal Watch General Medicine January 19, 2010
Case: woman 40 yr of age with
BMI 33; which abnormality best
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her 10-yr mortality? waist
circumference (36 in); fasting blood
glucose (110 mg/dL)
systolic blood pressure (BP; 140 mm
Hg)
triglycerides (185 mg/dL); exercise
test (stopped after stage 2)
answer
• —exercise test best
predictor
Fit and fat
• study confirmed earlier findings that sedentary
lifestyle doubles risk for premature death over 14
yr
• Fitness more important than weight for
measurement of health
• study showed fat but fit subjects lived longer than
thin but unfit subjects
• findings not replicated in other studies, but fitness
always shown to mitigate weight-related
morbidities
• urge patients to become as fit as possible,
regardless of their weight
Exercise
• not sufficient for weight loss
• improves variety of metabolic factors (small
dose-response effect) with or without weight loss
• recommend focusing initially on exercise duration
and frequency rather than on intensity
• That is why doing a body fat % is important. You
can tell patient even if you do not lose weight if on
your next visit your body fat is less you have more
muscle you are doing a good job and you are
healthier.
• By doing multiple measures you have multiple
ways to measure fitness.
Diet
• necessary for weight loss
• transtheoretical model’s stages of change applicable to
prescribing diet and weight loss strategies
• intervention should focus on stage of patient’s change
• diet type less important than adherence to Diet
• similar effectiveness seen with various popular diets,
including meal replacement (very low calorie), Atkins (low
carbohydrate), Ornish (vegetarian); Zone (balanced
macronutrient)
• mean intake 1400 calories/day on all diets
• Lowcarbohydrate approach possibly slightly better
• Universal use of low-fat diet no longer evidence-based
• patient should have adequate social support and frequent
visits with peer support, dietician, or physician
Rapid weight loss
• very low calorie diet (VLCD)—800 calories/day
• preplanned meals with adequate vitamins, minerals, and
proteins
• meta-analysis showed patients on VLCD lose weight twice
as quickly as those on traditional low-calorie diet (LCD;
1200 to 1400 calories/day) in short term;
• LCD in clinical setting results in loss of 5% to 10%
(average 7.5%) of patient’s original weight
• VLCD 15%
• weight loss in short term; VLCD indicated in patients who
want to lose high volume of weight without surgery
• VLCD indicated In patients with need for rapid weight loss
(eg, orthopedist recommends knee surgery, but requires
that patient first lose 50 lb or patient too heavy for bariatric
surgery table)
Average Weight Loss
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Low Calorie Diet 5 to 10% of body weight
7.5 % is average
Very Low Calorie Diet 15% of body weight
Gastric bypass 30% of body weight
A very low-calorie diet
(VLCD)
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A very low-calorie diet (VLCD) is a doctor-supervised diet that typically uses
commercially prepared formulas to promote rapid weight loss in patients who
are obese. These formulas, usually liquid shakes or bars, replace all food
intake for several weeks or months. VLCD formulas need to contain
appropriate levels of vitamins and micronutrients to ensure that patients meet
their nutritional requirements. Some physicians also prescribe VLCDs made
up almost entirely of lean protein foods, such as fish and chicken. People on a
VLCD consume about 800 calories per day or less.
VLCD formulas are not the same as the meal replacements you can find at
grocery stores or pharmacies, which are meant to substitute for one or two
meals a day. Over-the-counter meal replacements such as bars, entrees, or
shakes, should account for only part of one’s daily calories.
When used under proper medical supervision, VLCDs may produce significant
short-term weight loss in patients who are moderately to extremely obese.
VLCDs should be part of comprehensive weight-loss treatment programs that
include behavioral therapy, nutrition counseling, physical activity, and/or drug
treatment.
VLCDs
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VLCDs are designed to produce rapid weight loss at the start of a weight-loss
program in patients with a body mass index (BMI) greater than 30 and
significant comorbidities. BMI correlates significantly with total body fat
content. It is calculated by dividing a person’s weight in pounds by height in
inches squared and multiplied by 703.
Use of VLCDs in patients with a BMI of 27 to 30 should be reserved for those
who have medical conditions due to overweight, such as high blood pressure.
In fact, all candidates for VLCDs undergo a thorough examination by their
health care provider to make sure the diet will not worsen preexisting medical
conditions. Lastly, these diets are not appropriate for children or adolescents,
except in specialized treatment programs.
Very little information exists regarding the use of VLCDs in older adults.
Because adults over age 50 already experience depletion of lean body mass,
use of a VLCD may not be warranted. Also, people over 50 may not tolerate
the side effects associated with VLCDs because of preexisting medical
conditions or the need for other medicines. Doctors must evaluate on a caseby-case basis the potential risks and benefits of rapid weight loss in older
adults, as well as in patients who have significant medical problems or are on
medications. Furthermore, doctors must monitor all VLCD patients
regularly—ideally every 2 weeks in the initial period of rapid weight loss—to
be sure patients are not experiencing serious side effects.
VLCD
• A VLCD may allow a patient who is moderately to
extremely obese to lose about 3 to 5 pounds per week, for
an average total weight loss of 44 pounds over 12 weeks.
Such a weight loss can rapidly improve obesity-related
medical conditions, including diabetes, high blood
pressure, and high cholesterol.
• The rapid weight loss experienced by most people on a
VLCD can be very motivating. Patients who participate in
a VLCD program that includes lifestyle treatment typically
lose about 15 to 25 percent of their initial weight during
the first 3 to 6 months. They may maintain a 5-percent
weight loss after 4 years if they adopt a healthy eating plan
and physical activity habits.
side effects
• Many patients on a VLCD for 4 to 16 weeks report minor
side effects such as fatigue, constipation, nausea, or
diarrhea. These conditions usually improve within a few
weeks and rarely prevent patients from completing the
program. The most common serious side effect is gallstone
formation. Gallstones, which often develop in people who
are obese, especially women, are even more common
during rapid weight loss. Research indicates that rapid
weight loss may increase cholesterol levels in the
gallbladder and decrease its ability to contract and expel
bile. Some medicines can prevent gallstone formation
during rapid weight loss. Your health care provider can
determine if these medicines are appropriate for you
Maintaining Weight Loss
• Studies show that the long-term results of VLCDs vary widely, but
weight regain is common. Combining a VLCD with behavior therapy,
physical activity, and active follow-up treatment may help increase
weight loss and prevent weight regain.
• In addition, VLCDs may be no more effective than less severe dietary
restrictions in the long run. Studies have shown that following a diet of
approximately 800 to 1,000 calories produces weight loss similar to
that seen with VLCDs. This is probably due to participants’ better
compliance with a less restrictive diet.
• For most people who are obese, their condition is long-term and
requires a lifetime of attention even after formal weight-loss treatment
ends. Therefore, health care providers should encourage patients who
are obese to commit to permanent changes of healthier eating, regular
physical activity, and an improved outlook about food
Study showing Medifast's effectiveness in patients with type 2 diabetes
published in 'The Diabetes Educator'
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OWINGS MILLS, Md., February 11, 2008- /PRNewswire-FirstCall/ -- Medifast, Inc. (NYSE: MED) today announced that a study
conducted by researchers at the Johns Hopkins University Bloomberg School of Public Health, showing the Medifast Program
outperforms the American Diabetes Association (ADA) recommended diet for patients with type 2 diabetes, has been published in the
January/February issue of 'The Diabetes Educator'. The peer-reviewed journal is the official journal of the American Association of
Diabetes Educators.
The examiner of the study from Johns Hopkins University submitted the study and informed Medifast that the study has been published
in the most appropriate venue to help train diabetes educators about the effectiveness of Medifast Meal Replacements in the treatment
of type 2 diabetes. The study was finalized for publication within the last 12 months after being presented to physicians and scholars
attending the American Diabetes Association Convention in 2005.
"This study is one of many that validate the efficacy of Medifast Meal Replacements in the clinical setting," said Brad MacDonald,
Chairman of the Board, Medifast, Inc. "Medifast continues to invest in the research and development of its products and programs to
ensure that our claims to consumers are the most documented and credible in the industry."
In the study, the Medifast Program outperformed the ADA recommended diet in weight loss, adherence and biochemical outcomes.
These findings suggest a re-evaluation of the ADA recommendation, which currently does not promote portion-controlled meal
replacement programs in weight loss and weight maintenance for individuals with diabetes, is warranted.
The results of the study also suggest that meal replacements may achieve the same outcomes in diabetics as bariatric surgery (though
over the longer term), while mitigating the increased risk of morbidity and mortality associated with these more dangerous treatment
approaches.
"A close friend of mine had some serious complications because of type 2 diabetes and it scared me to death," said Medifast client
Steven Eldridge, of Raytown, MO. "I was suffering from the disease myself and decided to consult my doctor. He said the best thing I
could do is to lose the weight, and that's when I found Medifast. I lost 114 pounds in 5 months on the Medifast Program and am totally
off my diabetes medication for the first time in 6 years, which is an absolute miracle, and I have Medifast to thank!"
The study compared Medifast's effectiveness for weight control in people with type 2 diabetes to the standard ADA recommended
dietary guidelines. The study enlisted 112 overweight or obese people with type 2 diabetes using two weight loss approaches of equal
caloric prescription - the Medifast Program and a traditional reduced-calorie diet based on the ADA recommended dietary guidelines.
According to the results, participants randomized to receive Medifast lost twice as much weight and were twice as compliant with the
diet as participants following the standard ADA diet. Approximately 40 percent of the Medifast participants lost greater than 5 percent
of their initial weight, compared with 12 percent of those on the standard ADA diet. Additionally, 24 percent of the Medifast users
decreased or eliminated their diabetes medication, compared to 0 percent on the standard ADA diet.
Medifast will continually participate in studies in the future, which will add even more credibility to the Medifast Brand and Programs.
For more than 25 years Medifast has been prescribed by practitioners as a safe and effective program that yields significant results and
has been proven to provide significant weight loss of 2-5 pounds per week.
"Over 20,000 physicians have recommended Medifast since 1980 and millions of consumers have realized the health and wellness
benefit of our program," says Michael S. McDevitt, Chief Executive Officer, Medifast, Inc. "The publication of this study adds to
Medifast's already stellar reputation in the medical community."
The Medifast Plan
For Women
• The Medifast 5 & 1 Plan helps women lose weight quickly, leading to
tremendous improvements in overall health. Medifast is much more
than the traditional, fad diets that may have failed your patients in the
past. Medifast helps your patients lose the weight - and teaches them
how to keep it off! The Medifast program is convenient, portioncontrolled, and simple to follow. Your patients will see and feel results
in the first week!
• Most women start by ordering the Medifast for Women 4-Week
Package. With this package your patients receive the most popular
Medifast Meals - and save over $30!
• Medifast also has a unique line of shakes, specially formulated to meet
the specific health needs of women. Medifast Plus for Women's Health
Shakes contain black cohosh, Echinacea, and chaste tree berry - these
ingredients help reduce symptoms of menopause, such as hot flashes or
night sweats.
The Medifast Plan
For Men
• The Medifast 5 & 1 Plan helps your patients lose weight
quickly, improve their overall health, and take charge of
their eating for life. Remember, Medifast is a lifestyle
change, not just a short-term weight loss solution. We
won't abandon your patients the way fad diets have in the
past. Our Transition, Maintenance and Exercise Plans pick
up where the 5 & 1 Plan ends - and teach your patients
how to sustain their weight loss results long term!
• The quick weight loss results your patients experience will
inspire and motivate them to embrace Medifast as an
essential part of their new, healthy lifestyle.
• Most men start by ordering the Medifast for Men 4-Week
Package and save over $30 on the most popular Medifast
Meals.
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The Medifast Plan
For Seniors
Medifast for Seniors is a Medifast Program specifically designed for adults over age 70. The
Medifast for Seniors Program is different from the Medifast 5 & 1 Plan.
Maintaining a healthy weight is beneficial for people of all ages. As one gets older, achieving and
maintaining a healthy weight becomes crucial to their overall state of health. The Medifast for
Seniors Program is convenient and easy to follow, emphasizing portion-controlled eating at regular
intervals throughout the day.
Seniors have 2 options for Medifast Meal Plans. As their physician, you can help decide which
option is right for your patient.
OPTION 1: The Medifast 4 & 2 & 1 Plan
4 Medifast Meals + 2 Lean & Green Meals + 1 Healthy Snack
1000-2000 calories daily
100+ grams of carbohydrates daily
Weight loss will be slow and steady
Patient will not be in fat burning state with this plan
OPTION 2: The Medifast 5 & 2 & 2 Plan
5 Medifast Meals + 2 Lean & Green Meals + 2 Healthy Snacks
1,300-1,500 calories daily
130+ grams carbohydrates daily
Weight loss may be slower paced, but patient will still lose weight at a healthy rate
Patient will not be in fat-burning state with this plan
OPTIFAST Program
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At the heart of the OPTIFAST Program is a portion-controlled, calorically
precise, nutritionally complete diet that takes the guesswork out of eating. The
benefits of OPTIFAST shakes, soups and bars include:
High-quality, complete nutritionPre-portioned and calorie-controlled
servingsStimuli narrowingQuick and simple preparationFreedom from
having to make food choices
During the Active Weight Loss phase, patients consume only the OPTIFAST
meal replacements. Hunger typically goes away after the first week. Many
patients report increased energy, attributed to more stable blood sugar levels,
balanced diet, decreased weight, and increased activity level.
The active weight loss phase is followed by a 4-6 week transition period
during which participants gradually add self-prepared foods back to their diets.
Participants move to a long-term weight management program rich in fruits
and vegetables, grains and low-fat proteins. During the program they will have
learned techniques to include small amounts of their favorite foods into their
new healthy lifestyle. The Food & Nutrition section ofResources contains links
to many helpful nutrition and meal planning resources.
OPTIFAST provider
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Becoming an OPTIFAST provider means access to a vast array of expertise
and services to member clinics, including:
Skilled Resources
– The OPTIFAST Team includes former and current OPTIFAST Program
Directors, physicians, registered dietitians, registered nurses, nutrition
scientists, exercise physiologists and clinical researchers.
Professional Resources
– Key program staff learn how to manage a comprehensive weight
management program from business, medical, nutritional and educational
perspectives. Components include:
– • The OPTIFAST Program Training Startup Manual
– • Online Training Modules
– • 2-day live training in Minneapolis, MN
– • Ongoing mentoring by your OPTIFAST account manager
– • Regional OPTIFAST Conferences
Clinical Support Services
– In addition to customized assistance from their account manager,
OPTIFAST clinics receive access to a wealth of research data, marketing
materials and support, and operations support.
Optifast and Bariatric Surgery
• Nutritional therapy prior to bariatric procedures can
provide significant benefits to surgeons and patients alike:
• Presurgery
• Improved transition to postoperative diet and
behaviorReduced fatty liver and decrease in liver
volumeDecreased visceral adipose tissue
• Postsurgery
• Reduced risk of liver trauma and blood lossReduced
laparoscopic procedure timeIncreased weight loss first
year postoperatively
• Some OPTIFAST clinics and bariatric surgery centers
offer presurgical support programs to help prepare patients
for surgery. Many OPTIFAST clinics also welcome
bariatric patients into their overall long-term management
programs and continue to provide OPTIFAST product to
those patients who were started on OPTIFAST prior to
After weight loss
• myth that after successful weight loss, patients can
return to “sensible” (1800 calories/day) diet
• Patient must maintain 1400 calorie/day diet for rest of life
or weight will be regained
• supported by data from National Weight Control Registry
• maintaining weight loss requires high levels of physical
activity ( 1 hr of moderate-intensity exercise daily)
• Exercise 6 days a week
• low-fat or low-carbohydrate diet
• regular selfmonitoring of weight
• “grazing” rather than binging
• Avoid fast foods
• weekend diet and exercise regimen same as weekday
regimen
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NWCR Facts
You may find it interesting to know about the people who have enrolled in the registry thus far.
80% of persons in the registry are women and 20% are men.
The "average" woman is 45 years of age and currently weighs 145 lbs, while the "average" man is 49
years of age and currently weighs 190 lbs.
Registry members have lost an average of 66 lbs and kept it off for 5.5 years.
These averages, however, hide a lot of diversity:
– Weight losses have ranged from 30 to 300 lbs.
– Duration of successful weight loss has ranged from 1 year to 66 years!
– Some have lost the weight rapidly, while others have lost weight very slowly--over as many as
14 years.
We have also started to learn about how the weight loss was accomplished: 45% of registry
participants lost the weight on their own and the other 55% lost weight with the help of some type of
program.
98% of Registry participants report that they modified their food intake in some way to lose weight.
94% increased their physical activity, with the most frequently reported form of activity being
walking.
There is variety in how NWCR members keep the weight off. Most report continuing to maintain a
low calorie, low fat diet and doing high levels of activity.
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78% eat breakfast every day.
75% weigh themselves at least once a week.
62% watch less than 10 hours of TV per week.
90% exercise, on average, about 1 hour per day.
Persons successful at long-term weight
loss and maintenance continue to
consume a low-energy, low-fat diet.
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Shick SM, Wing RR, Klem ML, McGuire MT, Hill JO, Seagle H.
Department of Epidemiology, University of Pittsburgh School of Medicine, PA 15213, USA.
Comment in:
J Am Diet Assoc. 1998 Nov;98(11):1273.
OBJECTIVES: To describe the dietary intakes of persons who successfully maintained weight loss and to determine
if differences exist between those who lost weight on their own vs those who received assistance with weight loss (eg,
participated in a commercial or self-help program or were seen individually by a dietitian). Intakes of selected
nutrients were also compared with data from the third National Health and Nutrition Examination Survey (NHANES
III) and the 1989 Recommended Dietary Allowances (RDAs). SUBJECTS: Subjects were 355 women and 83 men,
aged 18 years or older, primarily white, who had maintained a weight loss of at least 13.6 kg for at least 1 year, and
were the initial enrollees in the ongoing National Weight Control Registry. On average, the participants had lost 30 kg
and maintained the weight loss for 5.1 years. METHODS: A cross-sectional study in which subjects in the registry
completed demographic and weight history questionnaires as well as the Health Habits and History Questionnaire
developed by Block et al. Subjects' dietary intake data were compared with that of similarly aged men and women in
the NHANES III cohort and to the RDAs. Adequacy of the diet was assessed by comparing the intake of selected
nutrients (iron; calcium; and vitamins C, A, and E) in subjects who lost weight on their own or with assistance.
RESULTS: Successful maintainers of weight loss reported continued consumption of a low-energy and low-fat diet.
Women in the registry reported eating an average of 1,306 kcal/day (24.3% of energy from fat); men reported
consuming 1,685 kcal (23.5% of energy from fat). Subjects in the registry reported consuming less energy and a lower
percentage of energy from fat than NHANES III subjects did. Subjects who lost weight on their own did not differ
from those who lost weight with assistance in regards to energy intake, percent of energy from fat, or intake of
selected nutrients (iron; calcium; and vitamins C, A, and E). In addition, subjects who lost weight on their own and
those who lost weight with assistance met the RDAs for calcium and vitamins C, A, and E for persons aged 25 years
or older. APPLICATIONS: Because continued consumption of a low-fat, low-energy diet may be necessary for longterm weight control, persons who have successfully lost weight should be encouraged to maintain such a diet.
Behavioral strategies of individuals who
have maintained long-term weight losses.
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McGuire MT, Wing RR, Klem ML, Hill JO.
University of Pittsburgh Medical Center, PA 15213, USA. [email protected]
OBJECTIVE: The purpose of the present study was to compare the behaviors of
individuals who have achieved long-term weight loss maintenance with those of
regainers and weight-stable controls. RESEARCH METHODS AND PROCEDURES:
Subjects for the present study were participants in a random-digit dial telephone survey
that used a representative sample of the U.S. adult population. Eating, exercise, selfweighing, and dietary restraint characteristics were compared among weight-loss
maintainers: individuals who had intentionally lost > or =10% of their weight and
maintained it for > or = 1 year (n = 69), weight-loss regainers: individuals who
intentionally lost > or = 10% of their weight but had not maintained it (n = 56), and
weight-stable controls: individuals who had never lost > or = 10% of their maximum
weight and had maintained their current weight (+/-10 pounds) within the past 5 years (n
= 113). RESULTS: Weight-loss maintainers had lost an average of 37 pounds and
maintained it for over 7 years. These individuals reported that they currently used more
behavioral strategies to control dietary fat intake, have higher levels of physical activity
(especially strenuous activity), and greater frequency of self-weighing than either the
weight-loss regainers or weight-stable controls. Maintainers and regainers did not differ
in reported levels of dietary restraint, but both had higher levels of restraint than the
weight-stable controls. DISCUSSION: These results suggest that weight-loss
maintainers use more behavioral strategies to control their weight than either regainers
or weight-stable controls. It would thus appear that long-term weight maintenance
requires ongoing adherence to a low-fat diet and an exercise regimen in addition to
continued attention to body weight.
What predicts weight regain in a
group of successful weight losers? .
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McGuire MT, Wing RR, Klem ML, Lang W, Hill JO.
Department of Psychiatry, University of Pittsburgh Medical School, USA.
[email protected]
Erratum in:
J Consult Clin Psychol 1999 Jun;67(3):282.
This study identified predictors of weight gain versus continued maintenance among
individuals already successful at long-term weight loss. Weight, behavior, and
psychological information was collected on entry into the study and 1 year later. Thirtyfive percent gained weight over the year of follow-up, and 59% maintained their weight
losses. Risk factors for weight regain included more recent weight losses (less than 2
years vs. 2 years or more), larger weight losses (greater than 30% of maximum weight
vs. less than 30%), and higher levels of depression, dietary disinhibition, and binge
eating levels at entry into the registry. Over the year of follow-up, gainers reported
greater decreases in energy expenditure and greater increases in percentage of calories
from fat. Gainers also reported greater decreases in restraint and increases in hunger,
dietary disinhibition, and binge eating. This study suggests that several years of
successful weight maintenance increase the probability of future weight maintenance
and that weight regain is due at least in part to failure to maintain behavior changes.
The prevalence of weight loss
maintenance among American adults.
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McGuire MT, Wing RR, Hill JO.
University of Pittsburgh Medical Center, PA, USA. [email protected]
BACKGROUND: Previous studies suggest that few individuals achieve long-term weight loss
maintenance. Because most of these studies were based on clinical samples and focused on only one
episode of weight loss, these results may not reflect the actual prevalence of weight loss maintenance
in the general population. DESIGN: A random digit dial telephone survey was conducted to
determine the point prevalence of weight loss maintenance in a nationally representative sample of
adults in the United States. Weight loss maintainers were defined as individuals who, at the time of
the survey, had maintained a weight loss of > or =10% from their maximum weight for at least 1 y.
The prevalence of weight loss maintenance was first determined for the total group (n = 500), and
then for the subgroup of individuals who were overweight (body mass index BMI > or =27 kg/m2 at
their maximum (n = 228). RESULTS: Weight loss was quite common in this sample: 54% of the
total sample and 62% of those who were ever overweight reported that they had lost > or =10% of
their maximum weight at least once in their lifetime, with approximately one-half to two-thirds of
these cases being intentional weight loss. Among those who had achieved an intentional weight loss
of > or =10%, 47-49% had maintained this weight loss for at least 1 y at the time of the survey; 2527% had maintained it for 5 y or more. Fourteen percent of all subjects surveyed and 21% of those
with a history of obesity were currently 10% below their highest weight, had reduced intentionally,
and had maintained this 10% weight loss for at least 1 y. CONCLUSIONS: A large proportion of the
American population has lost > or =10% of their maximum weight and has maintained this weight
loss for at least 1 y. These findings are in sharp contrast to the belief that few people succeed in longterm weight loss maintenance.
Three-year weight change in successful
weight losers who lost weight on a lowcarbohydrate diet.
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Obesity (Silver Spring). 2007 Oct;15(10):2470-7.
Phelan S, Wyatt H, Nassery S, Dibello J, Fava JL, Hill JO, Wing RR.
Department of Psychiatry and Behavioral Medicine, Brown Medical School, 196 Richmond Street,
Providence, RI 02903, USA. [email protected]
OBJECTIVE: The purpose of this study was to evaluate long-term weight loss and eating and
exercise behaviors of successful weight losers who lost weight using a low-carbohydrate diet.
RESEARCH METHODS AND PROCEDURES: This study examined 3-year changes in weight,
diet, and physical activity in 891 subjects (96 low-carbohydrate dieters and 795 others) who enrolled
in the National Weight Control Registry between 1998 and 2001 and reported >or=30-lb weight loss
and >or=1 year weight loss maintenance. RESULTS: Only 10.8% of participants reported losing
weight after a low-carbohydrate diet. At entry into the study, low-carbohydrate diet users reported
consuming more kcal/d (mean +/- SD, 1,895 +/- 452 vs. 1,398 +/- 574); fewer calories in weekly
physical activity (1,595 +/- 2,499 vs. 2,542 +/- 2,301); more calories from fat (64.0 +/- 7.9% vs. 30.9
+/- 13.1%), saturated fat (23.8 +/- 4.1 vs. 10.5 +/- 5.2), monounsaturated fat (24.4 +/- 3.7 vs. 11.0 +/5.1), and polyunsaturated fat (8.6 +/- 2.7 vs. 5.5 +/- 2.9); and less dietary restraint (10.8 +/- 2.9 vs.
14.9 +/- 3.9) compared with other Registry members. These differences persisted over time. No
differences in 3-year weight regain were observed between low-carbohydrate dieters and other
Registry members in intent-to-treat analyses (7.0 +/- 7.1 vs. 5.7 +/- 8.7 kg). DISCUSSION: It is
possible to achieve and maintain long-term weight loss using a low-carbohydrate diet. The long-term
health effects of weight loss associated with a high-fat diet and low activity level merits further
investigation.
Holiday weight management by successful
weight losers and normal weight
individuals.
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J Consult Clin Psychol. 2008 Jun;76(3):442-8.
Phelan S, Wing RR, Raynor HA, Dibello J, Nedeau K, Peng W.
Department of Psychiatry and Human Behavior, Brown Medical School, Providence, RI
02903, USA. [email protected]
This study compared weight control strategies during the winter holidays among
successful weight losers (SWL) in the National Weight Control Registry and normal
weight individuals (NW) with no history of obesity. SWL (n = 178) had lost a mean of
34.9 kg and had kept > or = 13.6 kg off for a mean of 5.9 years. NW (n = 101) had a
body mass index of 18.5-24.9 kg/m(2). More SWL than NW reported plans to be
extremely strict in maintaining their usual dietary routine (27.3% vs. 0%) and exercise
routine (59.1% vs. 14.3%) over the holidays. Main effects for group indicated that SWL
maintained greater exercise, greater attention to weight and eating, greater stimulus
control, and greater dietary restraint, both before and during the holidays. A Group x
Time interaction indicated that, over the holidays, attention to weight and eating
declined significantly more in SW than in NW. More SWL (38.9%) than NW (16.7%)
gained > or = 1 kg over the holidays, and this effect persisted 1 month later (28.3% and
10.7%, respectively). SWL worked harder than NW did to manage their weight, but they
appeared more vulnerable to weight gain during the holidays. (c) 2008 APA, all rights
reserved
Weight-loss maintenance in successful weight
losers: surgical vs non-surgical methods.
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Int J Obes (Lond). 2009 Jan;33(1):173-80. Epub 2008 Dec 2.
Bond DS, Phelan S, Leahey TM, Hill JO, Wing RR.
Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown
University/The Miriam Hospital, Providence, RI, USA. [email protected]
OBJECTIVE: As large weight losses are rarely achieved through any method except bariatric
surgery, there have been no studies comparing individuals who initially lost large amounts of weight
through bariatric surgery or non-surgical means. The National Weight Control Registry (NWCR)
provides a resource for making such unique comparisons. This study compared the amount of weight
regain, behaviors and psychological characteristics in NWCR participants who were equally
successful in losing and maintaining large amounts of weight through either bariatric surgery or nonsurgical methods. DESIGN: Surgical participants (n=105) were matched with two non-surgical
participants (n=210) on gender, entry weight, maximum weight loss and weight-maintenance
duration, and compared prospectively over 1 year. RESULTS: Participants in the surgical and nonsurgical groups reported having lost approximately 56 kg and keeping > or =13.6 kg off for 5.5+/-7.1
years. Both groups gained small but significant amounts of weight from registry entry to 1 year
(P=0.034), but did not significantly differ in magnitude of weight regain (1.8+/-7.5 and 1.7+/-7.0 kg
for surgical and non-surgical groups, respectively; P=0.369). Surgical participants reported less
physical activity, more fast food and fat consumption, less dietary restraint, and higher depression
and stress at entry and 1 year. Higher levels of disinhibition at entry and increased disinhibition over
1 year were related to weight regain in both groups. CONCLUSIONS: Despite marked behavioral
differences between the groups, significant differences in weight regain were not observed. The
findings suggest that weight-loss maintenance comparable with that after bariatric surgery can be
accomplished through non-surgical methods with more intensive behavioral efforts. Increased
susceptibility to cues that trigger overeating may increase risk of weight regain regardless of initial
weight-loss method.
Consistent self-monitoring of weight: a key
component of successful weight loss
maintenance.
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Obesity (Silver Spring). 2007 Dec;15(12):3091-6.
Butryn ML, Phelan S, Hill JO, Wing RR.
Department of Psychology, Drexel University, 245 N. 15th Street, MS 626, Philadelphia, PA 19102,
USA. [email protected]
OBJECTIVE: The objectives were to investigate the characteristics associated with frequent selfweighing and the relationship between self-weighing and weight loss maintenance. RESEARCH
METHODS AND PROCEDURES: Participants (n = 3003) were members of the National Weight
Control Registry (NWCR) who had lost >or=30 lbs, kept it off for >or=1 year, and had been
administered the self-weighing frequency assessment used for this study at baseline (i.e., entry to the
NWCR). Of these, 82% also completed the one-year follow-up assessment. RESULTS: At baseline,
36.2% of participants reported weighing themselves at least once per day, and more frequent
weighing was associated with lower BMI and higher scores on disinhibition and cognitive restraint,
although both scores remained within normal ranges. Weight gain at 1-year follow-up was
significantly greater for participants whose self-weighing frequency decreased between baseline and
one year (4.0 +/- 6.3 kg) compared with those whose frequency increased (1.1 +/- 6.5 kg) or
remained the same (1.8 +/- 5.3 kg). Participants who decreased their frequency of self-weighing were
more likely to report increases in their percentage of caloric intake from fat and in disinhibition, and
decreases in cognitive restraint. However, change in self-weighing frequency was independently
associated with weight change. DISCUSSION: Consistent self-weighing may help individuals
maintain their successful weight loss by allowing them to catch weight gains before they escalate and
make behavior changes to prevent additional weight gain. While change in self-weighing frequency
is a marker for changes in other parameters of weight control, decreasing self-weighing frequency is
also independently associated with greater weight gain.
Medications
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medicines really are not effective
phentermine—approved for 6 wk of use
weight usually returns upon termination of use
sibutramine – approved for 1 yr use ineffective
orlistat—prescription-strength approved for 2-yr use
topiramate—not approved for weight loss
exenatide—not approved for weight loss
drug vs placebo studies
average loss 5% of original weight; study results unreliable because
subjects placed on diet and exercise programs and behavioral therapy
before start of medication trial
• no data suggest >1-yr use of weight-loss medications reduces obesityrelated morbidity and mortality
• drugs ineffective because multiple biologic systems (eg, central
nervous system, endocrine system) affect appetite, and when one
suppressed, others remain active or compensate
Surgery
• gastric bypass twice as effective as best
dietary intervention
• risk for death within 30-day post-operative
period 0.5% to 2.0%
• factors affecting outcome include surgeon’s
skill and patients’ preexisting comorbidities
Background for obesity surgery
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obesity surgery differs from that of 7 to 10 yr ago
>50% of Americans overweight or obese
1 in 25 Americans qualify for weight-loss surgery
75% of obese children become morbidly obese adults
1 in 3 children born after 2000 will develop type 2 diabetes
each year 112,000 people die prematurely of obesity-related
conditions
(more than deaths from breast cancer, prostate cancer, and colorectal
cancer combined)
society incorrectly views obesity as result of acquired self-destructive
behavior, rather than as disease
obese individuals have lower rates of drug, tobacco, and alcohol use
than national averages
problem—food highly efficient vehicle for disease
Most smokers do not get lung cancer and few chronic alcohol abusers
get cirrhosis, but everyone who consumes more calories than they burn
will gain excess weight
Background for obesity surgery
• Candidates for weight-loss surgery
• National Institutes of Health (NIH) criteria
recommend weight-loss surgery for patients
with BMI over 40, or BMI over 35 plus
hypertension, heart disease, sleep apnea, or
diabetes
• nonsurgical weight-loss treatments have
about a 95% long-term failure rate
• bariatric surgery only scientifically proven
method for long-term weight loss; improves
or cures diabetes, hypertension, sleep apnea,
and other weight-related morbidities
Laparoscopic surgery
• now standard bariatric procedure
• compared to open procedures, results in reduced incidence
of wound infections, hernias, deep venous thrombosis,
pulmonary embolism, and postoperative pneumnia as well
as less pain and faster recovery
• only 1% to 2% of patients undergoing laparoscopy develop
wound infection, hernia, or both (compared to 1 in 6
patients undergoing open procedures)
• recent improvements—standardized procedures
• collaboration among surgeons nationally
• improved patient selection
• procedure should be done in patients <400 lb, preferably
<300 lb as it is safer and more effective
Goals of surgery
• gastric banding—restriction of caloric
intake by restricting volume required for
feeling of satiation
• patients eat 3 4-oz meals daily
• patients taught how to construct a lowcalorie meal
• gastric bypass—restriction plus
malabsorption
People loss weight
in Gastric Bypass
surgery by three
basic mechanisms,
What are they?
Answer
• 1. Hormonal
• 2. Malabsorption
• 3. Dumping syndrome.
• What exactly is the
mechanism for each method?
Answer
• 1. Hormonal is the result of reduced Ghrelin
in the stomach. It is a hormone made by the
stomach that makes you feel hungry
• 2. Malabsorption because of bypassing part
of the small intestine
• 3. Dumping syndrome is an autonomic
response to eating high osmolarity foods
that as they pass from the reduced stomach
directly into the jejunem cause sweating,
distension and tachycardia. You get a bad
feeling and the result is an Antibuse effect
used to limit drinking Alcohol
NEJM Volume 346:1623-1630May 23, 2002Number 21Next
Plasma Ghrelin Levels after Diet-Induced Weight Loss or Gastric Bypass Surgery
David E. Cummings, M.D., David S. Weigle, M.D., R. Scott Frayo, B.S., Patricia A. Breen,
B.S.N., Marina K. Ma, E. Patchen Dellinger, M.D., and Jonathan Q. Purnell, M.D.
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Our finding of markedly reduced ghrelin levels after gastric bypass suggests that suppression of
ghrelin can now be studied as a potential mechanism by which this procedure causes weight loss.
This hypothesis offers a plausible explanation for theparadoxical reduction of hunger between meals
that occurs after gastric bypass, as well as for the observation that the procedure is more effective
than gastroplasty in facilitating long-term weight loss.12,13,14,35,36,37,38,39,40 These operations
produce equivalent gastric restriction,35,41 but only gastric bypass isolates ghrelin cells from contact
with enteral nutrients.
The mechanism by which gastric bypass leads to a reduction in ghrelin levels remains to be
determined. Our data show thatingested nutrients powerfully regulate the level of circulating ghrelin.
Although an empty stomach is associated with an increasedghrelin level in the short term, it is
possible that the permanent absence of food in the stomach and duodenum that results fromgastric
bypass causes a continuous stimulatory signal that ultimately suppresses ghrelin production through
the process of "override inhibition." By this mechanism, continuous gonadotropin-releasing hormone
signaling initially stimulates but eventually suppresses gonadotropin secretion,42 and a similar
desensitization occurs with the unabated stimulation of growth hormone by growth-hormone–
releasing hormone.43 The possibility that override inhibition occurs in the case of ghrelin is suggested
by our data showing a progressive decline in the circulating level during an overnight fast (Figure
1 and Figure 2).24
In summary, 24-hour plasma ghrelin levels increase in response to diet-induced weight loss,
suggesting that ghrelin may play a part in the adaptive response that limits the amount of weight that
may be lost by dieting. We also found that ghrelin levels are abnormally low after gastric bypass,
raising the possibility that this operation reduces weight in part by suppressing ghrelinproduction.
These data suggest that ghrelin antagonists may someday be considered in the treatment of obesity.
Malabsorption
• Gastric bypass surgery bypasses the section of small bowel in which
most vitamins are digested and absorbed. Also, as seen below in the
excerpts taken from various medical sources, that stapling the stomach
can have some repercussions as far as vitamin digestion.
• Vitamin A
• Calcium
• Vitamin B12
– B12 fact sheet from NIH NOTE: sub lingual or B12 shots are
recommended
• Vitamin E
• Vitamin D
– Vitamin D fact sheet NIH
• Polyneuropathy (post stomach stapling)
• Selenium Deficiency
• Thiamin (vitamin B1 deficiency)
• Starvation
• Iron
Gastric dumping syndrome
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Gastric dumping syndrome, or rapid gastric emptyingis a condition where
ingested foods bypass the stomach too rapidly and enter the small intestine
largely undigested. It happens when the upper end of the small intestine,
thejejunum, expands too quickly due to the presence of
hyperosmolar[jargon] food from the stomach. "Early" dumping begins
concurrently or immediately succeeding a meal. Symptoms of early dumping
include nausea,vomiting, bloating, cramping, diarrhea, dizziness and fatigue.
"Late" dumping happens 1 to 3 hours after eating. Symptoms of late dumping
include weakness, sweating, and dizziness. Many people have both types. The
syndrome is most often associated with gastric surgery.
It is speculated that "early" dumping is associated with difficulty digesting fats
while "late" dumping is associated with carbohydrates.[citation needed]
Rapid loading of the small intestine with hypertonic stomach contents can lead
to rapid entry of water into the intestinal lumen. Osmotic diarrhea, distension
of the small bowel (leading to crampy abdominal pain), and hypovolemia can
result.
In addition, people with this syndrome often suffer from low blood sugar,
or hypoglycemia, because the rapid "dumping" of food triggers the pancreas to
release excessive amounts of insulin into the bloodstream. This type of
hypoglycemia is referred to as "alimentary hypoglycemia".
Gastric bypass
• stomach stapled and cut to make new smaller stomach
• intestine attached to new stomach
• Stomach still makes digestive secretions that mix with bile and
pancreatic secretions
• current procedures bypass only onethird of gastrointestinal (GI) tract
• possible to achieve weight loss without predisposing patient to
nutritional deficiencies
• stomach stapled and cut to make new smaller stomach
• intestine attached to new stomach
• Stomach still makes digestive secretions that mix with bile and
pancreatic secretions
• current procedures bypass only onethird of gastrointestinal (GI) tract
• possible to achieve weight loss without predisposing patient to
nutritional deficiencies
Comparing Surgical Procedures
for Treatment of Obesity
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What's the best choice: gastric bypass or gastric banding?
Bariatric surgery is the quickest fix for severe obesity, but patients must
carefully weigh benefits and risks before undergoing these invasive
procedures. Two reports in 2009 should provide some help with those
decisions.
In a prospective observational cohort study of perioperative complications (JW
Gen Med Jul 30 2009), researchers at 10 high-volume U.S. bariatric surgery
centers followed nearly 5000 patients who underwent open Roux-en-Y gastric
bypass, laparoscopic Roux-en-Y gastric bypass, or laparoscopic adjustable
gastric banding. Thirty-day mortality was significantly higher with open
bypass than with the other two procedures (2.1% vs. 0.2% and 0%). Incidence
of a composite 30-day endpoint (death, venous thromboembolism, operative
reintervention, and prolonged hospitalization) was highest with open bypass,
intermediate with laparoscopic bypass, and lowest with banding (7.8%, 4.8%,
and 1.0%, respectively); this general pattern of complication rates persisted
after adjustment for baseline differences between groups. These researchers
currently are conducting a study of longer-term outcomes for 2400 patients
(LABS-2).
Adjustable gastric banding
• band on outside of stomach causes
narrowing
• swallowed food fills and stretches narrowed
upper stomach and sends signal to brain that
entire stomach full
• tubing connects to port placed
subcutaneously at midline, just off linea
alba
• band tightness adjusted in office by
injecting saline into port
Sleeve gastrectomy
• new procedure; excises about 80% of stomach
along greater curve
• involves neither caloric restriction nor
malabsorption
• removes hormonal mediators of hunger (eg,
ghrelin production virtually eliminated)
• patients never hungry and have no desire to eat
• avoids nearly all longterm complications of gastric
bypass or implant, including nutritional
deficiencies
• preliminary results show efficacy higher than band
and slightly lower than bypass; reduction in risk
probably worth benefit
Benefits of weight loss
surgery
• much safer than in past
• (mortality rate 0.5%)
• about same as other major surgery (eg,
vascular surgery)
Weight reduction
• gastric band—European and Australian
data show reduction of 50% to 60% of
excess weight;
• data not replicated in United States
• US data show 40% to 45% weight reduction
at 3 yr
• gastric bypass— reduction of 65% to 75%
of excess weight, mostly in first 18 mo
Diabetes, Hypertension, Sleep Apnea
• Diabetes: gastric band—type 2 diabetes improves
in about 70% of patients (complete resolution in
some)
• Diabetes: gastric bypass—>90% improvement
rate
• majority cured (usually immediately after surgery
and the reason not totally clear)
• Hypertension: gastric band—about 55%
improvement rate and possible cure
• gastric bypass—about 75% improvement rate and
possible cure
• Sleep apnea: cured in nearly all (98%-99%)
patients by both procedures
Risks
• intestinal leaking—can cause peritonitis
•
•
•
•
•
Increases death rate from 1 in 200 to 1 in 15
most leaks successfully managed
rarely occurs after banding
occurs in 1% of patients with bypass
pulmonary embolism—1% for both procedures
(recent reductions due to aggressive prophylaxis);
• death—nearly 0% with banding; 0.5% with
bypass
• reoperation rate—4% in both procedures; major
complications—5% after banding;
• 5% to 8% after bypass
Follow-up
• because of high number of annual procedures,
nearly every physician treats patients with history
of bariatric Surgery
• nonabdominal or nonbariatric GI issues addressed
as in patients without history of bariatric surgery
• for upper GI complaints in patient with band, first
deflate band
• done by primary care physician or bariatric
surgeon
• gastric cancer—uncommon, but likely to present
at advanced stage (patient complaining of pain)
Follow-up
• Biliary disease—endoscopic retrograde
cholangiopancreatography (ERCP)
difficult in patients with history of bariatric
surger
• gastric bypass causes silent trauma to the
liver
• but improves or cures nonalcoholic
steatohepatitis (NASH)
• gastric bypass not recommended for
patients with active hepatitis B or C
• patient with biliary colic should be referred
for gallbladder removal
Complications
• early—patients with GI complications <60 days after
surgery should be sent back to bariatric surgeon
• most problems surgically related
• late complications after banding, most complications
implant-related (eg, infection, breakage, erosion, slippage)
• nausea, reflux, or vomiting indicative of complications and
should prompt emptying of band
• obtain x-ray
• after bypass, most commonly experienced complications
include internal hernia, strictures, and ulcers
• pain not normal after bypass
• Presence of pain suggestive of complications
• Intermittent cramping abdominal pain attributed to internal
hernia (most serious long-term complication) until proven
otherwise
Nutritional
deficiencies
• general malabsorption—food stream has
•
•
•
•
shorter transit time and less absorptive area
specific malabsorption—nutrient stream
does not contact specific areas of absorption
iron—after gastric bypass, 50% of
premenopausal women develop iron
deficiency anemia if not taking supplements
calcium—two-thirds have altered calcium
metabolism (likely vitamin D problem)
thiamine – uncommon, but serious; may
result in peripheral neuropathy (usually
irreversible)
Beriberi
• Beriberi is a neurological and cardiovascular disease. The three major
forms of the disorder are dry beriberi, wet beriberi, and infantile
beriberi.[14]
• Dry beriberi is characterized principally by peripheral neuropathy
consisting of symmetric impairment of sensory, motor, and reflex
functions affecting distal more than proximal limb segments and
causing calf muscle tenderness.[29]
• Wet beriberi is associated with mental confusion, muscular wasting,
edema, tachycardia, cardiomegaly, and congestive heart failure in
addition to peripheral neuropathy.[2]
• Infantile beriberi occurs in infants breast-fed by thiamin-deficient
mothers (who may show no sign of thiamine deficiency). Infants may
manifest cardiac, aphonic, or pseudomeningitic forms of the disorder.
Infants with cardiac beriberi frequently exhibit a loud piercing cry,
vomiting, and tachycardia.[14] Convulsions are not uncommon, and
death may ensue if thiamine is not administered promptly.[29]
• Following thiamine treatment, rapid improvement occurs generally
within 24 hours.[14] Improvements of peripheral neuropathy may
require several months of thiamine treatment.
Alcoholic brain disease
•
•
•
•
•
•
•
•
•
•
Nerve cells and other supporting cells (such as glial cells) of the nervous system require thiamine. Examples of
neurologic disorders that are linked to alcohol abuse include Wernicke’s encephalopathy (WE, Wernicke-Korsakoff
syndrome) and Korsakoff’s psychosis (alcohol amnestic disorder) as well as varying degrees of cognitive
impairment.[33]
Wernicke’s encephalopathy is the most frequently encountered manifestation of thiamine deficiency in Western
society,[34] though it may also occur in patients with impaired nutrition from other causes, such as gastrointestinal
disease,[34] those with HIV-AIDS, and with the injudicious administration of parenteral glucose or hyperalimentation
without adequate B-vitamin supplementation.[35] This is a striking neuro-psychiatric disorder characterized by
paralysis of eye movements, abnormal stance and gait, and markedly deranged mental function.[36]
Alcoholics may have thiamine deficiency because of the following:
inadequate nutritional intake: alcoholics tend to intake less than the recommended amount of thiamine.
decreased uptake of thiamine from the GI tract: active transport of thiamine into enterocytes is disturbed during acute
alcohol exposure.
liver thiamine stores are reduced due to hepatic steatosis or fibrosis.[37]
impaired thiamine utilization: magnesium, which is required for the binding of thiamine to thiamine-using enzymes
within the cell, is also deficient due to chronic alcohol consumption. The inefficient utilization of any thiamine that
does reach the cells will further exacerbate the thiamine deficiency.
Ethanol per se inhibits thiamine transport in the gastrointestinal system and blocks phosphorylation of thiamine to its
cofactor form (ThDP).[38]
Korsakoff Psychosis is generally considered to occur with deterioration of brain function in patients initially
diagnosed with WE.[39]. This is an amnestic-confabulatory syndrome characterized by retrograde and anterograde
amnesia, impairment of conceptual functions, and decreased spontaneity and initiative.<[29]
Following improved nutrition and the removal of alcohol consumption, some impairments linked with thiamine
deficiency are reversed; particularly poor brain functionality, although in more severe cases, Wernicke-Korsakoff
syndrome leaves permanent damage.
Nutritional deficiencies
•
•
•
•
•
•
•
•
•
•
•
•
fat-soluble vitamins (A, D, E, K) deficiencies develop slowly
vitamin B12 requires laboratory testing
30% of bariatric procedure patients deficient in vitamin B12
most asymptomatic
protein—not true malabsorptive deficiency; postoperatively
body’s use of fat and amino acids for energy and wastes protein;
recommendations—daily multivitamin usually sufficient to resolve or
prevent vitamin deficiencies;
prescribe 2 chewable vitamins (18 mg of iron per tablet) and 1200 mg
calcium with 400 IU vitamin D (eg, 2 Caltrate D tablets) daily
70 to 80 g of protein per day by supplementation during acute weight
loss phase
check serum levels frequently during rapid weight loss and annually
thereafter
recommend routinely checking calcium, vitamins A, B1, B9, B12, D,
E, and K, zinc, iron, and magnesium
start on multivitamin and thiamine (pending test results)
Other primary care issues
• stabbing pain (usually subxiphoid) likely
ulcer
• treat with proton pump inhibitor
• Serious cases may require liquid sucralfate
(Carafate)
• Severe pain surgical emergency
• wide variability among patients, especially
those who underwent surgery >5 yr ago
• when referring for bariatric surgery, most
important factors are surgeon’s experience
and multidisciplinary team (especially
The latest findings confirm that
obesity will soon overtake
tobacco use as the leading cause
of
preventable death in the United
States.
(A) True (B) False
Answer
• (B) False
Which of the following
diets was shown to be
effective for weight loss?
(A) Atkins diet
(B) Ornish diet
(C) Zone diet
(D) All the above
Answer
• (D) All the above
All the following are elements of
successful maintenance of weight
loss, except:
(A) High level of physical
activity
(B) Reduced caloric intake
(C) Regular self-monitoring of
weight
(D) Weight loss medications
Answer
• (D) Weight loss medications
Gastric bypass is
_________ the best dietary
intervention.
(A) As effective as
(B) Twice as effective as
(C) Five times more
effective than
(D) Less effective than
Answer
• (B) Twice as effective as
Bariatric surgery has been shown
to improve or cure which of the
following?
1. Diabetes
2. Hypertension
3. Sleep apnea
(A) 1 (B) 1,2 (C) 1,3 (D) 1,2,3
Answer
• 1. Diabetes
• 2. Hypertension
• 3. Sleep apnea
• (D) 1,2,3
The National Institutes of Health
(NIH) recommends weight loss
surgery for individuals with a
body
mass index of _______ if the
patient also has hypertension,
heart disease, sleep apnea, or
diabetes.
(A) 30 (B) 35 (C) 40 (D)
45
Answer
• (B) greater than 35
The first step in addressing
any upper gastrointestinal
complaint in a patient who
has had gastric banding
should be deflation of the
band.
(A) True (B) False
Answer
• (A) True
Gastric bypass causes
silent trauma to the:
(A) Kidneys (B) Liver
(C) Heart (D) Pancreas
Answer
• (B) Liver
Gastric bypass is not
recommended in patients with
which of the following?
(A) Active hepatitis B
(B) Active hepatitis C
(C) Nonalcoholic
steatohepatitis
(D) A and B
Peripheral neuropathy may result
from deficiency of which of the
following?
(A) Thiamine
(B) Vitamin D
(C) Calcium
(D) Vitamin B12
(E) A and D
Answer
• (A) Thiamine B1
(D) Vitamin B12
(E) A and D