Treatment of Obesity

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Treatment of Obesity

• Pennington Biomedical Research Center
• Division of Education

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Treatment options

• When does obesity threaten the health and life of
  a patient?
• Which patients have co-morbidities that make an
  aggressive treatment necessary?

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Steps in determining treatment

• Determine BMI.
• Assess complications and risk factors

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Steps in determining treatment

• Determine BMI-related health risk
• Determine weight reduction exclusions
• Mental illness
• Unstable medical condition
• Some medications
• Temporary
• Pregnancy or lactation

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Steps in determining treatment

• Possible exclusions
• Osteoporosis
• BMI in minimal or no-risk category
• History of mental illness
• Medications
• Permanent exclusions
• Anorexia nervosa
• Terminal illness
• Assess patient readiness

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Steps in determining treatment

• Treatment Options
• 1. Mild energy-deficit regimen
• Diet, diet and exercise, behavioral therapy
• 2. Aggressive energy-deficit regimen
• VLCD
• Extensive exercise program
• 3. Obesity drugs
• 4. Surgery

More extreme options
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Dietary treatment

• When someone is a few pounds overweight and is
  motivated to lose weight, dietary approach is a
  safe and effective method for weight loss. It is
  also the best method for helping to acquire new
  skills for maintaining a weight loss.

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Dieting with the Exchange List

• The Exchange diet.
• Monitor intake of carbohydrates, fat and protein
  as well as portion sizes.
• Includes foods from each group and can be used
  indefinitely.
• It also works well in weight maintenance.

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Dieting with the Exchange List

• Food is broken down into 6 categories
• Starch/Bread
• Meat
• Vegetables
• Fruit
• Milk
• Fat

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The Exchange List

• The number of exchanges is determined by the
  total number of calories required.
• Different for each person and depends on
• height, weight, and energy expenditure.

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Exchanges for Various Calorie Levels
Total Kcal/d 1200 1400 1500 1600 1700 1800 2000 2100 2200
Meat 4 4 5 6 6 6 6 6 6
Bread/ starch 5 7 7 7 8 9 10 11 11
Vegs 2 3 4 2 2 2 2 2 3
Fats 3 3 3 3 3 4 4 4 4
Fruit 3 3 3 3 3 3 3 3 4
Skim milk (cups) 2 2 2 - - - - - -
2 milk 2 2 2 2 2 3
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Example of daily exchange diet 1800 Kcals daily
BREAKFAST

• 1 c orange juice
• 2 slices of toast
• 1 hard-cooked egg
• 2 tsp margarine
• 1 c 2 milk
• Coffee or tea

• 2 Fruits
• 2 Breads
• 1 Meat
• 2 Fat
• 1 Milk
• Free Food

Yields
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Example of daily exchange diet 1800 Kcals daily
LUNCH

• ½ c tuna
• 2 slices whole wheat bread
• ½ c tomato slices
• Lettuce/cucumber salad
• 1 c sliced peaches
• 1 tsp margarine
• Tea with lemon

• 2 Meat
• 2 Bread
• 1 Vegetable
• Raw Vegetable
• 2 Fruit
• 2 Fat
• Free Foods

Yields
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Example of daily exchange diet 1800 Kcals daily

• 3 oz baked chicken
• ½ c mashed potato
• 1 small whole grain roll
• ½ c broccoli, ½ c carrots
• Tossed salad
• 1 Tbsp salad dressing
• 1 tsp margarine
• Coffee

• 3 meat
• 1 Bread
• 1 Bread
• 1 Vegetable
• Raw Vegetable
• 1 Fat
• 1 Fat
• Free Food

DINNER
Yields
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Example of daily exchange diet 1800 Kcals daily
EVENING SNACK

• 2 graham crackers
• 1 c 2 milk

• 1 Bread
• 1 Milk

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The Exchange Diet

• For more information please visit
• http//www.diabetes.org/home.jsp

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Dieting Using Calorie Controlled Portions

• MEAL REPLACEMENT PLAN
• Liquid formula or a packaged item
• Fixed number of calories to replace a meal.
• Control portion sizes
• Fat, carbohydrate, calories
• Balanced meals

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Meal Replacement Plan

• 4 types of meal replacers
• Powder mixes
• Shakes
• Bars
• Prepackaged Meals

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Meal Replacement Plan

• An intake of five fruits and vegetables is
  recommended.
• Effective
• Convenient
• Nutritionally balanced

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ExampleA MEAL REPLACEMENT PLAN
Breakfast Meal Replacement
Lunch Sensible Meal or Meal Replacement
Dinner Sensible Meal
Snacks Fruit, vegetable, fat-free yogurt or cheese, nuts, pretzels, or air-popped popcorn
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Exercise

• Adults 30-45 minutes of exercise three to five
  days each week
• Include 5-10 minute warm up and cool down
• Weight loss at least 30 minutes of aerobic
  activity a day for five days

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Exercise

• Children at least 60 minutes, and up to several
  hours of physical activity per day for children
  and adolescents
• Several bouts of physical activity lasting 15
  minutes or more each day

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Exercise

• Energy Balance maintaining weight.
• Positive energy balance leads to weight gain.
• Negative energy balance leads to weight loss.

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Exercise Benefits

• Exercise builds lean body mass.
• Walking, running and doing physical activity can
  burn two to three times more calories than
  similar amount of time sitting.
• With exercise there is an improvement in overall
  physical fitness.
• Exercise improves maintenance of weight after
  weight loss.

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Exercise

• For Weight Loss
• 150 to 200 minutes of moderate physical activity
  each week
• diet for weight loss
• For Improved Health
• An exercise program with less than 150
  minutes a week and lower intensity can result in
  improvement in cardio-respiratory fitness.

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Aerobic Activity

• Aerobic exercise is any extended activity that
  makes the lungs and heart work harder while using
  the large muscle groups in the arms and legs at a
  regular, even pace.
• EXAMPLES 
• Brisk walking
•     Jogging
•    Bicycling
•    Swimming
•       Aerobic dancing
•       

Racket sports   Lawn mowing   Ice or roller
skating Using aerobic equipment (treadmill,
stationary bike)
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Anaerobic Activity

• Anaerobic activity is short bursts
  of very strenuous activity using large muscle
  groups
• (Ex weight lifting, curls, power lifting).
• Helps build and tone muscles, but it does
  not benefit the heart
  or the lungs.

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Very Low Calorie Diets (VLCD)

• Formula diet of 800 calories or less.
• Must be under proper medical supervision.
• Produce significant weight loss in moderately to
  severely obese patients.

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VLCD Facts

• Not recommended for pregnant or breastfeeding
  women
• Not appropriate for children or adolescents
• Not recommended for older individuals

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Behavioral Treatment

• Widely used strategy
• Based on adjusting energy balance
• Individual treatment, or
• Group Format
• (Around 18-24 weeks)
• One of the most successful treatment programs

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Group Approaches

• Social support
• integration into social network and positive
• interactions with others.
• Individual feels support, acceptance, and
  encouragement by others.

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Behavior Treatment

• Need to change ones approach
• thinking
• feelings
• actions
• to eating and physical activity.

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Behavioral targets
Total energy intake
Total energy expenditure
_
Weight

Eating
Activity
Targets of behavioral therapy
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Behavior Therapy Important Components

• Making Lifestyle Change a Priority
• Establishing a Plan for Success

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Behavior Therapy Important Components

• 3. Setting Goals
• Calories, fat, physical activity.
• Short-term goal of losing 1 to 2 pounds a week.
• Choose specific, attainable, and realistic goals.
  
• Have a long-term goal.

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Behavior Therapy Important Concepts

• 4. Keeping Track of Eating and Exercising
• Tracking to raise awareness.
• Self monitoring.
• Record time, activating event, place and quantity
  of eating, and activity behaviors.

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Behavior Therapy Important Concepts

• 5. Avoiding a Food Chain Reaction
• Stimulus control.
• Learning to recognize cues.

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Behavior Therapy Important Concepts

• Techniques to conquer eating triggers include
• eating regular meals
• eating at the same time and place
• use smaller plates
• keeping accessible food out of sight
• eating only when hungry
• avoiding activities that encourage eating

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Behavior Therapy Important Concepts

• 6. Changing Eating and Activity Patterns
• slowing pace of eating
• reducing portion sizes
• measuring food intake
• leaving food on plate
• improving food choices
• eliminating second servings

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Behavior Therapy Important Concepts

• Changing Eating and Activity Patterns
• Programmed exercise vs lifestyle
• Lifestyle activity preferable for weight loss.

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Behavior Therapy Important Concepts

• 7. Contingency Management
• Positive reinforcement (reward)
• An effective reward - immediate, desirable, and
  given based on meeting a specific goal.
• Tangible rewards - a new CD
• Intangible reward taking time off

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Behavior Therapy Important Concepts

• 8. Cognitive Behavioral Strategies
• Traditional behavioral treatment components with
  emphasis on thinking patterns that may affect
  eating behaviors.

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Behavior Therapy Important Concepts

• 9. Stress Management
• Stress is a primary predictor of overeating and
  relapse.
• Stress management skills

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Drug Treatment of Obesity Indicated when

• BMI is greater than 30
• BMI is higher than 27 and there are other
  cardiovascular complications
• After several attempts diet alone is not enough

Cardiovascular complications include
Hypertension, Dyslipidemia, Coronary Heart
Disease, Type 2 Diabetes, and Sleep Apnea
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Drug Therapy

• Commonly prescribed drugs for the treatment of
  obesity include
• Phentermine
• Sibutramine
• Orlistat

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Drug Therapy Phentermine

• Brand names are Adipex-P, Obenix, Oby-Trim
• Most commonly prescribed medication for weight
  loss.
• Phentermine increases norepinephrine, a
  neurotransmitter in the brain that decreases
  appetite.
• Phentermine has stimulant properties, and it may
  cause high blood pressure or irregular heat
  beats.

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Drug Therapy Sibutramine

• The brand name is Meridia
• Sibutramine induces weight loss by reducing food
  intake.
• It stimulates the
• satiety centers in the brain.
• Sibutramine use may increase heart rate and blood
  pressure.
• Sibutramine is not recommended for someone with
  uncontrolled hypertension, tachycardia, or
  serious heart, liver, or kidney disease.

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Drug Therapy Orlistat

• The Brand name is Xenical
• Orlistat prevents the digestion of dietary fat.
• Bowel habits will likely change.
• Leads to improvement in blood lipids.
• Multivitamin supplement is encouraged.

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Surgical Treatment of Obesity

• Criteria used for surgical treatment
• BMI is 40 or higher
• BMI of 35-39.9 and a serious obesity-related
  health problem
• such as Type 2 diabetes, hypertension, heart
  disease, or sleep apnea

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Types of GI surgeries available

• Restrictive
• Malabsorptive
• Combined restrictive/malabsorptive

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GI Surgeries Restrictive

• Purely restrictive operations only limit food
  intake and do not interfere with the normal
  digestive process.
• Create a pouch.
• Delay in food emptying.

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Restrictive Operations Examples

• Adjustable gastric banding
• A band is clamped to create a pouch.

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Restrictive Operations Examples

• 2. Vertical banded gastroplasty.
• Uses the band and staples to create
• a small pouch. Not commonly used
• today.

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Restrictive Operations Advantages

1. Generally safer than malabsorptive procedures.
2. Done via laparoscopy allowing for smaller
   incisions.
3. Surgeries can be reversed if necessary.
4. Result in few nutritional deficiencies.

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Restrictive Operations Disadvantages

1. Smaller weight loss.
2. Can lead to weight gain over time.
3. No change in eating habits.
4. Success depends on the patients willingness to
   adopt a healthy lifestyle.

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Restrictive Operations Risks

• Overeating leading to vomiting.
• Break in tubing.
• Problems leading to a second operation.
• These risks need to be taken into account by any
  individual considering the surgery!

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Malabsorptive Operations

• The main malabsorptive operation is the
  jejunoileal bypass which is not performed today
  because of the high incidence of health
  complications.

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Combined Restrictive and Malabsorptive Operations

• Restricts both food intake and the amount of
  calories and nutrients the body absorbs.

• Roux-en-Y gastric bypass (RGB)
• Creates a pouch.
• Connects the small intestine
• to the pouch, bypassing large
• sections of the intestines.

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Combined Restrictive and Malabsorptive Operations

• Biliopancreatic diversion (BPD)
• Remove portion of stomach.
• Connect this directly to the
• final segment of the small intestine
• completely bypassing sections of
• intestines.

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Combined Operations Advantages

1. Rapid weight loss.
2. Maintain good weight loss for 10 years or more.
3. Can lose up to 75-80 of excess weight.
4. May lead to greater improvement in health.

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Combined Operations Disadvantages

1. Can be difficult.
2. May result in long-term nutritional deficiencies.
3. Decreased absorption of iron and calcium.
4. Require fat soluble vitamin supplementation.
5. May have dumping syndrome.

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Combined Operations Risks

1. May lead to complications.
2. Greater risk for abdominal hernias.
3. The risk of death may be higher.

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Bariatric Surgery Facts

• Procedures cost from 20,000 to 35,000.
• Medical insurance coverage varies by state.

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NIDDK (National Institute of Diabetes and
Digestive and Kidney Diseases)

• The patient should consider the following
  questions prior to weight loss surgery
• Are you unlikely to lose weight or keep weight
  off long-term with non-surgical measures?
• Are you well informed about the surgical
  procedure and the effects of treatment?
• Are you determined to lose weight and improve
  your health?

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NIDDK

• 4. Are you aware of how your life may change
  after the operation?
• 5. Are you aware of the potential for serious
  complications, dietary restrictions, and
  occasional failures?
• 6. Are you committed to lifelong medical
  follow-up and vitamin/mineral supplementation?

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Conclusions

• When there are no complications or co-morbidities
  associated with obesity, dietary, exercise and
  behavioral approaches are the safest and best
  approaches.
• For successful weight loss to become permanent,
  an individual has to adopt new behaviors to
  maintain weight loss.

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Conclusion

• It is very important for individuals considering
  initiation of weight loss drug therapy or
  surgeries to be well aware of the risks
  associated with the treatments.
• Once all risks are understood, then ultimately it
  is the individuals decision to go along with the
  treatment or not.

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References Behavior Therapy and VLCD Information

• http//www.medhelp.org/NIHlib/GF-390.html
• Foreyt, J.P., Poston, W.S.C., Jr. (1998a). The
  role of the behavioral counselor in obesity
  treatment. J Am Diet Assoc, 10(Supplement 2),
  S27-S30
• Foreyt, J.P., Poston, W.S.C., Jr. (1998b). What
  is the role of cognitive-behavior therapy in
  patient management? Obes Res, 6(Supplement 1),
  18S-22S
• Foster, G.D., Wadden, T.A., Vogt, R.A., Brewer,
  G. (1997). What is a reasonable weight loss?
  Patients' expectations and evaluations of obesity
  treatment outcomes. J Consult Clin Psychol, 65,
  79-85

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References Behavior therapy

• Poston, W.S.C., Jr., Hyder, M.L., O'Byrne, K.K.,
  Foreyt, J.P. (2000). Where do diets, exercise,
  and behavior modification fit in the treatment of
  obesity? Endocrine, 13(2), 187-192.
• Wadden, T.A., Sarwer, D.B., Berkowitz, R.I.
  (1999). Behavioural treatment of the overweight
  patient. Baillieres Best Pract Res Clin
  Endocrinol Metab, 13(1), 93-107.
• Wing, R.R. (1993). Behavioral approaches to the
  treatment of obesity. In G. Bray, C. Bouchard
  P. James (Eds.), Handbook of Obesity (pp.
  855-873). New York Marcel Dekker, Inc.
• Wing, R.R., Tate, D.F. (2002). Behavior
  modification for obesity. In J.F. Caro (Ed.),
  Obesity. http//www.endotext.org/obesity/index.htm
  

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Sites Drug Therapy Info Surgery

• http//www.cdc.gov
• National Heart, Lung, and Blood Institute,
  Clinical Guidelines on the Identification,
  Evaluation, and Treatment of Overweight and
  Obesity in Adults, 1998.
• Astrup A, Hansen DL, Lundsgaard C, Toubro S.
  Sibutramine and energy balance. Int J Obes Relat
  Metab Disord 1998 Aug 22 Suppl 1 S30-S35.
• Bray GA, Ryan DH, Gordon D, et al. A double-blind
  randomized placebo-controlled trial of
  sibutramine. Obes Res 1996 May 4(3) 263-70.
• Heal DJ, Aspley S, Prow MR, et al. Sibutramine a
  novel anti-obesity drug. A review of the
  pharmacological evidence to differentiate it from
  d-amphetamine and d-fenfluramine. Int J Obes
  Relat Metab Disord 1998 Aug 22 Suppl 1 S18-S29.

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References Drug therapy Surgery

• www.meridia.net
• Waitman, JA, Aronne LJ. Phrmacotherpay of
  obesity. Obesity Management 1 15-19, 2005.
• Greenway, F. Surgery for obesity. Endocrinology
  and Metabolism Clinics of North America
  25(4)1005-1027.
• Surgery for morbid obesity What patients should
  know. 3rd Ed. American Society for
  BariatricSurgery, Gainesville, FL 2001.
• http//win.niddk.nih.gov/publications/gastric.htm
  
• Escott-Stump, S. Nutrition and Diagnosis-Related
  Care. 5th Edition. 2002.

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References Exercise

• http//www.cdc.gov
• Ross R, Jansses I, Dawson J, Kungl A-M, Kuk JL,
  Wong SL, Nguyen-Day T-B, Lee SL, Kilpatrick K,
  Hudson R. Exercise induced reduction in obesity
  and insulin resistance in women a randomized
  controlled trial. Obesity Research 12789-798,
  2004.
• Jakicic JM, Marcus BH, Gallagher KI, Napolitano
  M, Lang W. Effects of exercise duration and
  intensity on weight loss in overweight, sedentary
  women. JAMA 10 1323-1330, 2003.
• Ross R, Katzmarzyk PT. Cardio respiratory fitness
  is associated with diminished total and abdominal
  obesity independent of body mass index.
  International Journal of Obesity 27 204-210,
  2003.
• McArdle WD, Katch FL, and Katch VL. Exercise
  Physiology Energy, Nutrition and Human
  Performance, 5th Edition. Lippincott Williams
  Wilkins 2004.

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References Diet

• http//www.cdc.gov
• Noakes M, Foster PR, Keogh JB, Clifton PM. Meal
  replacements are as effective as structured
  weight-loss diets for treating obesity in adults
  with features of metabolic syndrome. J Nutr. 2004
  Aug134(8)1894-9.
• Truby H, Millward D, Morgan L, Fox K, Livingstone
  MB, DeLooy A, Macdonald I. A randomised
  controlled trial of 4 different commercial weight
  loss programmes in the UK in obese adults body
  composition changes over 6 months.Asia Pac J
  Clin Nutr. 2004 Aug13(Suppl)S146.
• http//www.slim-fast.com/plan/index.asp?bhcp1
  Accessed September 16, 2004.
• Halford JCG, Ball MF, Pontin EE, Maharjan LB,
  Dovey TM, Pinkney JH, Wilding JPH, Mela DJ. The
  impact of using meal-replacements versus standard
  dietetic advice on body weight, appetite, mood,
  and satisfaction during a 12-week weight control.
  North American Association for the Study of
  Obesity Conference, November 14-18, 2004, Las
  Vegas, Nevada.

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Pennington Biomedical Research CenterDivision
of Education

• Heli J. Roy, PhD, RD
• Beth Kalicki
• Division of EducationPhillip Brantley, PhD,
  DirectorPennington Biomedical Research
  CenterClaude Bouchard, PhD, Executive Director

Edited October 2009
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About Our Company
The Pennington Biomedical Research Center is a
world-renowned nutrition research
center.   Mission To promote healthier lives
through research and education in nutrition and
preventive medicine.   The Pennington Center has
several research areas, including   Clinical
Obesity Research Experimental Obesity Functional
Foods Health and Performance Enhancement Nutrition
and Chronic Diseases Nutrition and the
Brain Dementia, Alzheimers and healthy
aging Diet, exercise, weight loss and weight loss
maintenance   The research fostered in these
areas can have a profound impact on healthy
living and on the prevention of common chronic
diseases, such as heart disease, cancer,
diabetes, hypertension and osteoporosis.   The
Division of Education provides education and
information to the scientific community and the
public about research findings, training programs
and research areas, and coordinates educational
events for the public on various health
issues.   We invite people of all ages and
backgrounds to participate in the exciting
research studies being conducted at the
Pennington  Center in Baton Rouge, Louisiana. If
you would like to take part, visit the clinical
trials web page at www.pbrc.edu or call (225)
763-3000.