Weight Management Strategies Medical and Nutritional Therapy by qingyunliuliu

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									Weight Management
Strategies: Medical and
Nutritional Therapy
What is Successful
Weight Loss?
n   Common definition: Lose at least 10%
    of starting weight and keep it off at
    least one year.
What is the Goal of
Obesity Treatment?
n   Specifically, the goal of obesity
    treatment should be refocused from
    weight loss alone, which is often
    aimed at appearance, to weight
    management, achieving the best
    weight possible in the context of
    overall health. –FTC Panel, Commercial
    Weight Loss Products and Programs
    What Consumers Stand To Gain and Lose,
    1997
http://www.ftc.gov/os/1998/03/weightlo.rpt.htm accessed 3-13-06
Who Should Consider A Weight
Management Intervention?

n   Persons with a BMI of >30
n   Persons with a BMI between 25-29.9
    OR a high-risk waist circumference,
    and two or more risk factors
n   Persons who are ready to change

    NHLBI Obesity Education Initiative. The Practical Guide
    Identification, Evaluation, and Treatment of Overweight
    and Obesity in Adults. NHLBI 00-4084, 2000.
Obesity-Associated Risk
Factors: High Absolute Risk
n   Established coronary heart disease
n   Other atherosclerotic diseases
n   Type 2 diabetes
n   Sleep apnea


    NHLBI Obesity Education Initiative. The Practical
    Guide Identification, Evaluation, and Treatment of
    Overweight and Obesity in Adults. NHLBI 00-4084,
    2000.
Obesity-Associated Risk
Factors: 3 or More = ↑ Risk
n   Hypertension
n   Cigarette smoking
n   High low-density lipoprotein cholesterol
n   Low high-density lipoprotein cholesterol
n   Impaired fasting glucose
n   Family history of early cardiovascular
    disease
n   Age (male ≥ 45 years, female ≥ 55 years)
 NHLBI Obesity Education Initiative. The Practical Guide Identification,
 Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI
 00-4084, 2000.
Other Obesity-Associated
Risk Factors
n   Osteoarthritis
n   Gallstones
n   Stress incontinence
n   Gynecological abnormalities

    NHLBI Obesity Education Initiative. The Practical
    Guide to Identification, Evaluation, and Treatment of
    Overweight and Obesity in Adults. NHLBI 00-4084,
    2000.
How Much and How Fast?
n   NIH guidelines recommend a weight loss of
    .5 to 1 pound/week for persons with a BMI
    of 27-35 and 1-2 pounds a week for those
    with a BMI>35 kg/m2
n   Allow 6 months to achieve 10% weight loss
n   After 6 months, focus should shift to weight
    maintenance for 6 months
n   Following this, weight loss efforts may
    resume (NIH, 1998)
Weight Loss Goals

n   R.4.0. Individualized goals of weight loss
    therapy should be to reduce body weight at
    an optimal rate of 1-2 lbs per week for the
    first 6 months and to achieve an initial
    weight loss goal of up to 10% from
    baseline.
n   These goals are realistic, achievable, and
    sustainable.
    Strong, Imperative

     American Dietetic Association Evidence Analysis Library Adult
     Wt Mgt Guidelines, accessed 2/07
Rates of Weight Loss Vary

n   Men will lose weight faster than
    women of similar size, due to higher
    LBM and RMR
n   A heavier person (who has higher
    energy needs) will lose weight faster
    than a smaller person on the same
    caloric regimen
Modest Weight Loss and
Health: Diabetes Prevention
n   A 7% weight loss (mean 15 pounds)
    through diet and exercise in high risk
    individuals was associated with a 58%
    reduction of diabetes incidence in the
    Diabetes Prevention Program DPP Research
    Group. N Engl J Med. 2002 Feb 7;346(6):393-403.

n   An average 7.7 pound weight loss was
    associated with a 58% reduction in diabetes
    incidence in high risk individuals in the
    Finnish Diabetes Prevention study. FDPS Group.
    N Engl J Med 344:1343–1350, 2001
Modest Weight Loss and
Health: Hypertension
n   Weight loss of as little as 4.5 kg (10
    pounds) will improve or prevent
    hypertension in a large segment of
    overweight persons. Seventh Report of the Joint
    National Committee on Prevention, Detection, Evaluation,
    and Treatment of High Blood Pressure (JNC 7)
    http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf


n   Clinically significant long-term reductions in
    blood pressure and reduced risk for
    hypertension can be achieved with modest
    weight loss and increased physical activity.
    American Dietetic Association Evidence Analysis Library,
    Hypertension and hyperlipidemia.
    http://www.adaevidencelibrary.org/
Modest Weight Loss and
Health: Hyperlipidemia
n   The ATP-III guidelines recommend a 10%
    weight loss in overweight persons with
    hyperlipidemia.
    http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf

n   A weight loss of ≥2.25 kg was associated
    with a 40-50% reduction in cardiovascular
    risk factors in the Framingham Offspring
    Study (BP, triglyceride, TC, FBS, HDL) Karason
    K et al. Int J Obes Relat Metab Disord 1999;23:948-56.
Modest Weight Loss and
Health: Diabetes
n   Calorie restriction and weight loss improves
    insulin sensitivity and glycemic control in
    obese patients with Type 2 diabetes. Henry RR
    et al. J Clin Endocrinol Metab 1985;61:917-25; Kelly DE et al. J Clin
    Endocrinol MEtab 1993;77:1287-93.

n   A 5% weight loss can decrease FBG, insulin,
    A1C concentrations and medication
    requirements. Wing RR et al. Arch Intern Med
    1987;147:1749-53.
Setting Weight
Management Goals
n   Many severely overweight persons
    have unrealistic expectations in setting
    weight loss goals (Blackburn, 1998)
n   Even modest weight loss may produce
    significant improvements in health
n   For some persons (especially those
    with BMI of 25-29.9) weight
    maintenance may be a goal
Evaluation of Body Wt

n   R.1.1 Body mass index (BMI) and waist
    circumference should be used to classify
    overweight and obesity, estimate risk for
    disease, and to identify treatment options.
n   BMI and waist circumference are highly
    correlated to obesity or fat mass and risk of
    other diseases (NHLBI report). Fair,
    Imperative

American Dietetic Association Evidence Analysis Library Adult Wt Mgt
Guidelines, accessed 2/07
Estimation of Energy
Needs
n   R.5.0 Estimated energy needs should be
    based on RMR. If possible, RMR should be
    measured (e.g., indirect calorimetry).
n   If RMR cannot be measured, then the Mifflin
    -St. Jeor equation using actual weight is
    the most accurate for estimating RMR for
    overweight and obese individuals. Strong,
    Conditional

American Dietetic Association Evidence Analysis Library Adult Wt Mgt
Guidelines, accessed 2/07
Readiness to Change: A
Brief Assessment
n   Has the individual sought weight loss
    on his/her own initiative?
n   What has led the patient to seek
    weight loss now?
n   What are the patient’s stress level and
    mood?
n   Does the individual have an eating
    disorder?
Readiness to Change: A
Brief Assessment
n   Does the individual understand the
    requirements of treatment and believe
    that he/she can fulfill them?
n   How much weight does the patient
    expect to lose?
NIH Recommended
Interventions
n   Dietary therapy
n   Physical activity
n   Behavior therapy
n   Pharmacotherapy
n   Bariatric surgery
Comprehensive Wt Mgt
Program
n   R.2.0 Weight loss and weight
    maintenance therapy should be based
    on a comprehensive weight
    management program including diet,
    physical activity, and behavior therapy.
    The combination therapy is more
    successful than using any one
    intervention alone. Strong,
    Imperative
    American Dietetic Association Evidence Analysis Library Adult Wt Mgt
    Guidelines, accessed 2/07
Dietary Interventions
Optimal Length of Wt Mgt
Therapy
n   R.3.0. Medical Nutrition Therapy for weight
    loss should last at least 6 months or until
    weight loss goals are achieved, with
    implementation of a weight maintenance
    program after that time.
n   Greater frequency of contacts between the
    patient and practitioner may lead to more
    successful weight loss and maintenance.
    Strong, Imperative
    American Dietetic Association Evidence Analysis Library Adult Wt
    Mgt Guidelines, accessed 2/07
Goals of Weight
Management (NIH)
n   Achievement of healthy body weight
    (or close to desired BMI)
n   Select a realistic goal—no more than 1
    to 1.5 lb/week
n   Prevent loss of LBM, especially from
    heart and brain
n   Support psychosocial factors
Reduced Calorie
Diets
n   R.6.0 An individualized reduced calorie diet
    is the basis of the dietary component of a
    comprehensive weight management
    program.
n   Reducing dietary fat and/or carbohydrates is
    a practical way to create a caloric deficit of
    500 – 1000 kcals below estimated energy
    needs and should result in a weight loss of 1
    – 2 lbs per week. Strong, Imperative
    American Dietetic Association Evidence Analysis Library Adult Wt
    Mgt Guidelines, accessed 2/07
Balanced Energy-
Restricted Diet
n   Is the most widely-prescribed method
    of weight reduction
n   Should be nutritionally adequate
    except for energy
n   Energy level varies with individual’s
    size, sex, and activity, ranging from
    800 kcals to 1500 kcals (NIH, 1998)
Balanced Energy-
Restricted Diet
n   Should be relatively high in carbohydrate
    (50-55% of total kcals)
    – CHO sources should be fruits, vegetables, whole
      grains
n   Include generous protein (15-25% of kcals)
    for increased satiety and to assure adequate
    supply
n   Fat < 30% of kcals
n   Increased fiber to improve satiety (NIH,
    1998)
Balanced Energy-
Restricted Diet
n   Alcohol and high-sugar foods should
    be limited to limit excess energy
n   Use of non-nutritive sweeteners and
    fat replacements may improve the
    palatability of the diet
n   Vitamins and mineral supplements
    may be needed in programs that
    provide <1200 kcals for women or
    1800 kcals for men (NIH, 1998)
Exchange System Diets

n   Allow flexibility in making
    food choices while limiting
    total caloric intake
n   Provides framework for
    healthy balance of nutrients
n   May be too complex or
    restrictive for some clients
Nutrition Education

n   R.10.0 Nutrition education should be
    individualized and included as part of the
    diet component of a comprehensive weight
    management program.
n   Short term studies show that nutrition
    education (e.g. reading nutrition labels,
    recipe modification, cooking classes)
    increases knowledge and may lead to
    improved food choices. Fair, Imperative
    American Dietetic Association Evidence Analysis Library Adult Wt
    Mgt Guidelines, accessed 2/07
Eating Frequency and
Patterns
n    R.7.0 Total caloric intake should be
     distributed throughout the day, with the
     consumption of 4 to 5 meals/snacks per day
     including breakfast.
n    Consumption of greater energy intake
     during the day may be preferable to evening
     consumption. Fair, Imperative


    American Dietetic Association Evidence Analysis Library Adult Wt
    Mgt Guidelines, accessed 2/07
Portion Control

n   R.8.0 Portion control should be
    included as part of a comprehensive
    weight management program. Portion
    control at meals and snacks results in
    reduced energy intake and weight
    loss. Fair, Imperative


    American Dietetic Association Evidence Analysis Library Adult Wt
    Mgt Guidelines, accessed 2/07
Meal Replacements

n    R.9.0 For people who have difficulty with self
     selection and/or portion control, meal replacements
     (e.g., liquid meals, meal bars, calorie-controlled
     packaged meals) may be used as part of the diet
     component of a comprehensive weight
     management program.
n    Substituting one or two daily meals or snacks with
     meal replacements is a successful weight loss and
     weight maintenance strategy. Strong,
     Conditional


    American Dietetic Association Evidence Analysis Library Adult Wt
    Mgt Guidelines, accessed 2/07
Low Glycemic Index Diets

n    R.11a A low glycemic index diet is not
     recommended for weight loss or
     weight maintenance as part of a
     comprehensive weight management
     program, since it has not been shown
     to be effective in these areas. Strong,
     Imperative

    American Dietetic Association Evidence Analysis Library Adult Wt
    Mgt Guidelines, accessed 2/07
Lowfat Dairy Foods

n   R.11b. In order to meet current nutritional
    recommendations, incorporate 3-4 servings
    of low fat dairy foods a day as part of the
    diet component of a comprehensive weight
    management program.
n   Research suggests that calcium intake lower
    than recommended levels is associated with
    increased body weight. However, the effect
    of dairy and/or calcium at or above
    recommended levels on weight
    management is unclear. Fair, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt
Guidelines, accessed 2/07
Low Carbohydrate Diets

n   R.11c Having patients focus on reducing
    carbohydrates rather than reducing calories and/or
    fat may be a short term strategy for some
    individuals.
n   Research indicates that focusing on reducing
    carbohydrate intake (<35% of kcals from
    carbohydrates) results in reduced energy intake.
n   Consumption of a low-carbohydrate diet is
    associated with a greater weight and fat loss than
    traditional reduced calorie diets during the first 6
    months, but these differences are not significant
    after 1 year. Fair, Conditional

    American Dietetic Association Evidence Analysis Library Adult Wt
    Mgt Guidelines, accessed 2/07
Very Low Calorie Diets
(VLCD)
n   Diets providing 200-800 kcals/day
n   Hypocaloric but relatively rich in protein (.8-
    1.5 g/kg/day)
n   Designed to include adequate vitamins,
    minerals, electrolytes, and EFAs
n   Completely replace usual meal intake
n   Usually given for 12-16 weeks
n   Usually reserved for those with BMI>30; or
    27-30 with risk factors

        NHLBI, 2000
Protein Sparing Modified
Fast (PSMF)
n   Uses real food
n   Contains 1.5 g protein/kg IBW as lean
    meat, fish and poultry
n   May include low-carbohydrate
    vegetables
n   Only fat is that present in the protein
    sources
    NIH NHLBI The practical guide. Identification, evaluation, and
    treatment of overweight and obesity in adults. NHLBI, 2000
Commercial VLCD Liquid
Diets
n   Contain 33-70 g of
    protein, 30-45 g
    CHO, small amount
    of fat
n   Provides 400-800
    kcals
n   Patients lose 20 kg
    in 12 to 16 weeks
NIH NHLBI The practical guide.
Identification, evaluation, and treatment of
overweight and obesity in adults. NHLBI,
2000
VLCDs
n   Cardiac complications a concern
n   Risks include potassium loss as well as
    body protein (higher in the less obese)
n   Requires close medical supervision and
    monitoring of serum electrolytes
n   But VLCDs may be a more
    effective method of weight
    loss for some
    (Anderson et al Am J Clin Nutr 74;579:2001)
Dietary Therapy: NIH
Guidelines
n   Very low calorie diets (VLCDs) should
    not be used routinely for weight loss
    therapy because they require special
    monitoring and supplementation
n   LCDs may be just as effective

NIH NHLBI The practical guide. Identification, evaluation, and
treatment of overweight and obesity in adults. NHLBI, 2000
Behavioral Therapy in
Weight Management
Behavioral Therapy: NIH
Guidelines
n   Self-monitoring
n   Stress management
n   Stimulus control
n   Problem-solving
n   Contingency management
n   Cognitive restructuring
n   Social support
Behavior Therapy in Wt
Mgt
n   R.13.0 A comprehensive weight management
    program should make maximum use of multiple
    strategies for behavior therapy (e.g. self
    monitoring, stress management, stimulus control,
    problem solving, contingency management,
    cognitive restructuring, and social support).
n   Behavior therapy in addition to diet and physical
    activity leads to additional weight loss. Continued
    behavioral interventions may be necessary to
    prevent a return to baseline weight. Strong,
    Imperative

     American Dietetic Association Evidence Analysis Library Adult Wt
     Mgt Guidelines, accessed 2/07
Self Monitoring

n   Records of place and time of food
    intake
n   Accompanying thoughts and feelings
n   Helps identify the physical and
    emotional settings in which eating
    occurs
n   Provides feedback on progress and
    puts responsibility on the patient
Problem Solving

n   Process for defining the eating or
    weight problem
n   Generating possible solutions;
    evaluating the solutions, choosing the
    best one
n   Trialing the new behavior, evaluating
    outcome and generating alternatives
Stimulus Control

Modification of
n The settings or the chain of events
  that precede eating
n The kinds of foods consumed
n The consequences of eating
  – Become mindful of satiety cues
  – Put fork down between bites
  – Pausing during meals
Cognitive Restructuring

n   Teaches patients to identify, challenge,
    and correct negative thoughts
n   Positive self-talk
Behavior Modification

n    Most effective in mildly obese (20-40%
     overweight)
n    Patients can maintain losses of 20-25
     pounds
n    Longer programs more successful
n    Many patients regain the weight they
     lost over time
    NIH NHLBI The practical guide. Identification, evaluation, and
    treatment of overweight and obesity in adults. NHLBI, 2000
Weight Loss Medications
Pharmacological Therapy
NIH Guidelines
n    Should be used only in the context of
     a program that includes lifestyle
     changes
n    If lifestyle changes do not promote
     weight loss after 6 months, drugs
     should be considered
n    Limited to those with BMI ≥30; or ≥27
     with risk factors
    NIH NHLBI The practical guide. Identification, evaluation, and
    treatment of overweight and obesity in adults. NHLBI, 2000
Wt Loss Medications

n   R.14.0 FDA-approved weight loss medications may
    be part of a comprehensive weight management
    program.
n   Dietitians should collaborate with other members of
    the health care team regarding the use of FDA-
    approved weight loss medications for people who
    meet the NHLBI criteria.
n   Research indicates that pharmacotherapy may
    enhance weight loss in some overweight and obese
    adults. Strong, Imperative


    American Dietetic Association Evidence Analysis Library Adult Wt Mgt
    Guidelines, accessed 2/07
Catecholaminergic Drugs
n   Appetite suppressants
n   Act on the brain, increasing the availability of
    norepinephrine
n   Schedule II anorexic agents
     – High potential for abuse
     – Include amphetamine, phenmetrazine HCl
     – Not recommended for weight management
n   Schedule III agents
     – Some potential for abuse
     – Include benzphetamine HCl, phendimetrazine
       tartrate
See Table 21-5 Krause 12th edition, p. 551
Catecholaminergic Drugs

n   Schedule IV agents
    – Includes diethypropion HCl, manzindol
      HCl, phentermine HCl, phentermine resin
    – Low potential for abuse
    – Can raise blood pressure, so prescribed
      with caution in patients with hypertension


      NIH NHLBI The practical guide. Identification, evaluation, and
      treatment of overweight and obesity in adults. NHLBI, 2000
Serotonin Reuptake
Inhibitors
n   Includes sibutramine (Meridia)
n   Inhibits the reuptake of serotonin and
    norepinephrine
n   Initially developed to treat depression
n   Use caution in hypertension, CHD,
    arrhythmias, CHF

    NIH NHLBI The practical guide. Identification, evaluation, and
    treatment of overweight and obesity in adults. NHLBI, 2000
Orlistat (Xenical)
n   Lipase inhibitor
n   Acts directly on the gastrointestinal tract to
    inhibit fat absorption
n   Associated with reduced LDL-C and
    increased HDL; improved glycemic control,
    reduced blood pressure
n   Some concern about fat soluble vitamins
n   Side effects: oily spotting, fecal urgency,
    flatus with discharge
      NIH NHLBI The practical guide. Identification, evaluation, and
      treatment of overweight and obesity in adults. NHLBI, 2000
FDA Approves Reduced Dose of
Orlistat for Over the Counter
n   Over the counter dose
    of orlistat, a lipase
    inhibitor
n   Half the dose of
    prescription form
    (Xenical)
n   The only FDA-approved
    over the counter wt
    mgt drug
n   Available summer 2007
Serotoninergic Agents

n   Increase serotonin levels in the brain
n   Fenfluramine hydrochloride and
    dexfenfluramine HCl (Fen-Phen) were
    removed from the market in 1997 due
    to association with heart valve disease
    and pulmonary hypertension
Pharmacological Obesity
Treatments
n   Weight loss of about 1 lb/week can be
    expected
n   Most weight loss will occur within the
    first 6 months of therapy
n   Significant weight maintenance as long
    as the drug treatment is continued
n   Most patients regain weight if
    medication is stopped
Pharmacological Obesity
Treatments
n   Weight-loss medications lead to an
    additional weight loss of 5 to 22
    pounds more than with non-drug
    obesity treatments
n   Two to 20 kg total loss, usually during
    first 6 months of treatment
n   When drugs are discontinued, weight
    regain occurs
Physical Activity and
Weight Management
Physical Activity
n   R.12.0 Physical activity should be part of a
    comprehensive weight management program.
    Physical activity level should be assessed and
    individualized long-term goals established to
    accumulate at least 30 minutes or more of
    moderate intensity physical activity on most, and
    preferably, all days of the week, unless medically
    contraindicated.
n   Physical activity contributes to weight loss, may
    decrease abdominal fat, and may help with
    maintenance of weight loss. Strong, Imperative

    American Dietetic Association Evidence Analysis Library Adult Wt
    Mgt Guidelines, accessed 2/07
Physical Activity: NIH
Guidelines
n    Physical activity increases energy
     expenditure and plays an integral role in
     weight maintenance
n    Reduces the risk of heart disease more than
     weight loss alone
n    Reduces body fat, prevents decrease in
     muscle mass during weight loss
n    All adults: goal of 30 minutes or more of
     moderate-intensity physical activity on most
     and preferably all days.
    NIH NHLBI The practical guide. Identification, evaluation, and
    treatment of overweight and obesity in adults. NHLBI, 2000
Role of Physical Activity
in Weight Management
n   Physical activity usually will not lead to
    a greater weight loss over diet alone in
    a 6-month period (NIH, 2000)
n   Physical activity is most helpful in
    preventing weight regain
n   Physical activity also is beneficial in
    reducing risk for heart disease and
    diabetes beyond the effect of weight
    loss
Role of Physical Activity
in Weight Management
n   Exercise helps balance the loss of LBM
    and reduction in RMR caused by
    hypocaloric diets
n   A combination of aerobic exercise and
    resistance training is recommended
n   Even when weight loss does not occur,
    loss of body fat often does
n   May require 2 months to see loss of
    weight through exercise
U.S. Dietary Guidelines
2005
n   Suggest 60 minutes of moderate-vigorous
    activity on most days of the week to prevent
    weight gain in adulthood
n   To sustain weight loss in adulthood: at
    least 60-90 minutes of daily moderate-
    intensity physical activity
n   Achieve physical fitness by including
    cardiovascular conditioning, stretching
    exercises for flexibility, and resistance
    exercises or calisthenics for muscle strength
    and endurance.
    http://www.health.gov/dietaryguidelines/dga2005/recommendati
    ons.htm
Role of Physical Activity
in Weight Management
 Other Benefits:
 —Improved sense of well-being
 —Relief of boredom
 —Sense of control
 —Relief from depression
Bariatric Surgery
n   R.15.0. Dietitians should collaborate with
    other members of the health care team
    regarding the appropriateness of bariatric
    surgery for people who have not achieved
    weight loss goals with less invasive weight
    loss methods and who meet the NHLBI
    criteria.
n   Separate ADA evidence based guidelines are
    being developed on nutrition care in
    bariatric surgery. Strong, Imperative
     American Dietetic Association Evidence Analysis Library Adult Wt
     Mgt Guidelines, accessed 2/07
Bariatric Surgery: NIH
Guidelines
n   Option for well-informed and
    motivated patients with clinically
    severe obesity (BMI≥40 or BMI ≥35
    with serious co-morbid conditions




    NIH NHLBI The practical guide. Identification, evaluation, and
    treatment of overweight and obesity in adults. NHLBI, 2000
Candidates for Bariatric
Surgery
n   BMI of 40 or more—about 100 pounds
    overweight for men and 80 pounds for
    women
n   BMI between 35 and 39.9 and a serious
    obesity-related health problem such as type
    2 diabetes, heart disease, or severe sleep
    apnea
n   Willingness to make associated lifestyle
    changes
Bariatric Surgery Options

n   Restrictive
n   Malabsorptive
n   Combination restrictive/malabsorptive
Restrictive Procedures

n    Adjustable gastric banding (AGB) a
    hollow band made of silicone rubber is
    placed around the stomach near its upper
    end, creating a small pouch and a narrow
    passage into the rest of the stomach
n   Vertical banded gastroplasty. VBG uses
    both a band and staples to create a small
    stomach pouch (not often used today)
Restrictive Surgery:
Adjustable Gastric Band
Diet After Surgery

n   After restrictive surgeries, patients can
    only eat ½ cup to 1 cup of food at a
    time
n   Foods often must be soft and chewed
    thoroughly
n   Patients who eat too fast or the wrong
    kinds of food may have vomiting
Restrictive Procedures:
Advantages
n   Don’t interfere with the normal
    digestive process
n   Easier to perform and generally safer
    than malabsorptive surgeries
n   AGB often done laparoscopically
n   Can be reversed if necessary
Restrictive Procedures:
Disadvantages
n   Generally results in less weight loss
n   Patients generally lose about half of
    their excess body weight in the first
    year after restrictive procedures
n   Only 20% keep weight off over 10
    years, though there is evidence that
    AGB is more effective than VBG
Restrictive/Malabsorptive
Procedures
n   Roux-en-Y gastric bypass (RGB) is the
    most common
n   The surgeon creates a small stomach pouch
    to restrict food intake. Next, a Y-shaped
    section of the small intestine is attached to
    the pouch to allow food to bypass the lower
    stomach, the duodenum and the first
    portion of the jejunum.
n   This reduces the amount of calories and
    nutrients the body absorbs.
Restrictive/Malabsorptive:
Roux en Y
Restrictive/Malabsorptive
Procedures: Advantages
n   Patients lose weight quickly and
    continue to lose 18-24 months after
    the procedure
n   With RGB, many patients maintain a
    weight loss of 60 to 70 percent of their
    excess weight for 10 years or more
Restrictive/Malabsorptive
Procedures: Disadvantages
n   More difficult to perform
n   More likely to result in long-term
    nutritional deficiencies (calcium, iron)
n   Greater risk of dumping syndrome
n   Increased likelihood of complications
    including hernia (decreased with
    laparoscopic procedures)
Weight Management—
Children
n   Goals: Weight maintenance or slowing
    of gains
n   Grow into weight
n   If severely obese, lose no more than 1
    lb monthly to reach desired adult
    weight for height
Weight Management in
Children
n At risk at BMI 85% to 95%ile; obese
  at 95%
n Review parents’ history—height,
  weight, etc.
n Weight management in children is a
  family affair
Weight Management in
Children
n   Overweight children should try to
    achieve weight maintenance or
    slowing of the rate of weight gain, not
    weight loss
n   Depends on age and degree of
    overweight
n   Once adult height is achieved, weight
    loss is necessary to improve health
Summary

n   Even modest weight loss can
    produce improvements in overall
    health in persons who are
    overweight (lipids, BG, insulin,
    blood pressure)
n   Most persons will need sustained,
    long-term lifestyle interventions to
    achieve significant weight loss

								
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