Treatment of Obesity

Treatment of Obesity Pennington Biomedical Research Center Division of Education Treatment options Questions to ask When does obesity threaten the health and life of a patient? Which patients have co-morbidities that make an aggressive treatment necessary? PBRC 2005 Steps in determining treatment Determine BMI – Drug treatment is NOT to be used when BMI is under 27. Assess complications and risk factors PBRC 2005 Steps in determining treatment Determine BMI-related health risk Determine weight reduction exclusions – Temporary • • • • Pregnancy or lactation Mental illness Unstable medical condition Some medications PBRC 2005 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 PBRC 2005 Steps in determining treatment Treatment Options 1. Mild energy-deficit regimen Diet Diet and exercise 2. Aggressive energy-deficit regimen VLCD Extensive exercise program 3. Obesity drugs 4. Surgery -More extreme optionsPBRC 2005 Diet When someone is a few pounds overweight and is motivated to lose weight, there are safe and effective methods to lose weight and to maintain a weight loss. PBRC 2005 Dieting with the Exchange List: INFO The Exchange diet was created by the American Dietetic Association and the American Diabetic Association as a treatment for diabetes and other chronic conditions. The diet is an easy way to monitor intake of carbohydrates, fat and protein as well as portion sizes. It is a balanced system with foods from each group and can be used indefinitely. It also works well in weight maintenance. PBRC 2005 Dieting with the Exchange List Food is broken down into 6 categories: Starch/Bread Meat Vegetables Fruit Milk Fat PBRC 2005 The Exchange List The number of exchanges used per day is determined by the total number of calories required by the individual. The number is different for each person and depends on that individual’s height, weight, and energy expenditure. The most accurate way to determine the number of exchanges needed is with the help of a registered dietitian, health professional, or a trained fitness professional. PBRC 2005 Exchanges for Various Calorie Levels Total 1200 1400 1500 calories/ day Meat Bread/ starch Vegetable Fats Fruit Skim milk (cups) 1600 1700 1800 2000 2100 2200 4 5 2 3 3 2 4 7 3 3 3 2 5 7 4 3 3 2 6 7 2 3 3 - 6 8 2 3 3 - 6 9 2 4 3 - 6 10 2 4 3 - 6 11 2 4 3 - 6 11 3 4 4 - 2% milk 2 2 2 2 2 3 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 Yields 2 Fruits 2 Breads 1 Meat 2 Fat 1 Milk Free Food PBRC 2005 Example of daily exchange diet: 1800 Kcals daily LUNCH ½ c tuna 2 slices whole wheat bread ½ c tomato slices Lettuce/cucumber salad Yields 1 c sliced peaches 1 tsp margarine Tea with lemon 2 Meat 2 Bread 1 Vegetable Raw Vegetable 2 Fruit 2 Fat Free Foods PBRC 2005 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 DINNER Yields 3 meat 1 Bread 1 Bread 1 Vegetable Raw Vegetable 1 Fat 1 Fat Free Food PBRC 2005 Example of daily exchange diet: 1800 Kcals daily EVENING SNACK 2 graham crackers 1 c 2% milk 1 Bread 1 Milk PBRC 2005 The Exchange Diet For more information on the diet, you can visit: http://www.diabetes.org/home.jsp PBRC 2005 Dieting Using Calorie Controlled Portions MEAL REPLACEMENT PLAN The rationale behind this plan is the use of a liquid formula or a packaged item with a fixed number of calories to replace a meal. By controlling portion sizes, fat and carbohydrate, a person can control calories. The replacement items are balanced and contain a mix of protein, carbohydrate and fat as well as other nutrients. PBRC 2005 Meal Replacement Plan 4 types of meal replacers: Powder mixes Shakes Bars Prepackaged Meals The usual plan is to use a meal replacement for one or two meals a day while having sensible meals that combine lean meat, starch, vegetables and fruit for the other meals during the day PBRC 2005 Meal Replacement Plan An intake of five fruits and vegetables is recommended. A meal replacement program is more effective for losing weight than a conventional, structured weight loss diet. Meal replacements offer a convenient, nutritionally balanced weight loss alternative to conventionally structured weight loss diets. PBRC 2005 A MEAL REPLACEMENT PLAN Breakfast Lunch Dinner Snacks Meal Replacement Sensible Meal or Meal Replacement Sensible Meal Fruit, vegetable, fat-free yogurt or cheese, nuts, pretzels, or air-popped popcorn PBRC 2005 Example: -ExerciseThe American College of Sports Medicine recommends that adults get 30-45 minutes of exercise three to five days each week, maintaining the intensity for the duration of the exercise Each session should contains a 5-10 minute warm up and cool down period If weight loss is a major goal, aerobic activity should last at least 30 minutes a day for five days each week. PBRC 2005 Exercise: facts The National Association for Sport and Physical Education (NASPE) recommends at least 60 minutes, and up to several hours of physical activity per day for children and adolescents Children should participate in several bouts of physical activity lasting 15 minutes or more each day It is important to choose an activity that is fun so that motivation to continue the activity will remain high PBRC 2005 Exercise Maintaining, gaining, and losing weight are tied to Energy Balance. Positive energy balance leads to weight gain. Negative energy balance leads to weight loss. Maintaining weight means that an energy balance has been reached. Physical activity and caloric intake balance each other out when an individual is at weight maintenance. PBRC 2005 Exercise: Benefits Exercise can build lean body mass, which burns more calories than fat. Walking, running and doing physical activity can burn two to three times more calories than a similar amount of time sitting. Weight loss similar to diet can be achieved by exercise alone. With exercise there is an improvement in overall physical fitness and a reduction in blood pressure. Exercise also improves maintenance of weight after weight loss. PBRC 2005 Exercise For Weight Loss 150 to 200 minutes of moderate physical activity each week combined with a diet for weight loss can result in reduced body weight and fat. It is important not to compensate for the exercise calories with food. For Improved Health An exercise program with less than 150 minutes a week and lower intensity can result in improvement in cardio-respiratory fitness. PBRC 2005 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. Aerobic activities help the heart grow stronger and more efficient. Aerobic activities use more calories than other activities. Brisk walking Jogging Bicycling Swimming Aerobic dancing EXAMPLES Racket sports Lawn mowing Ice or roller skating Using aerobic equipment (treadmill, stationary bike) PBRC 2005 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. During the anaerobic activity, glycogen (carbohydrate stored in muscle and liver) is used for energy and at the end of anaerobic activity, lactic acid is produced. This gives a burning sensation in the muscles. PBRC 2005 Very Low Calorie Diets (VLCD) VLCDs are commercially prepared formulas of 800 calories or less that replace all usual food intake. They are not the same as over-the-counter meal replacements, which are meant to be substituted for one or two meals a day. When used under proper medical supervision, they effectively produce significant short-term weight loss in moderately to severely obese patients. VLCD are prescribed and supervised by a medical doctor. PBRC 2005 VLCD: Facts Generally safe when used under proper medical supervision in patients with a BMI greater than 30 Use of VLCD in patients with a BMI of 27 to 30 should be reserved for those who have medical complications resulting from their obesity. Not recommended for pregnant or breastfeeding women Not appropriate for children or adolescents, unless in specialized treatment programs Generally not recommended for usage in older individuals because of the potential of side effects caused by preexisting conditions PBRC 2005 Behavioral Treatment Widely used strategy Based on adjusting energy balance Individual treatment Group Format (Around 18-24 weeks) One of the most successful ways of treating obese individuals PBRC 2005 Group Approaches Social support – integration into social network and positive interactions with others. – Individual feels support, acceptance, and encouragement by others. This is why some of the better weight loss programs work. PBRC 2005 Behavior Treatment Long-term lifestyle changes require more than simply watching what one eats and how much one exercises. It requires changing one’s approach (thinking, feelings, and actions) to eating and physical activity. A key component to any weight loss approach. Results in losing about 1 pound a week . Average weight loss is about 20 pounds after six months. PBRC 2005 Behavioral targets Weight = Total energy intake Eating _ Total energy expenditure Activity Targets of behavioral therapy PBRC 2005 Behavior Therapy: Important Components 1. Making Lifestyle Change a Priority Making changes to last a lifetime is a difficult thing to do. Important to make health a top priority. 2. Establishing a Plan for Success Determine diet and exercise plan prior to beginning, set a start date, and consider barriers that may make it difficult to reach goals. PBRC 2005 Behavior Therapy: Important Components 3. Setting Goals Setting goals for calories, fat, physical activity and other modifiable behaviors. Targets a short-term goal of losing 1 to 2 pounds of weight a week, and establishes the caloric intake and exercise amounts needed to reach this goal. Effective goals are chosen that are: specific, attainable and realistic (walk 30 minutes five times a week, eat 5 servings of fruits and vegetables). To reach a long-term goal, complete a series of smaller steps that get closer to the ultimate prize. PBRC 2005 Behavior Therapy: Important Concepts 4. Keeping Track of Eating and Exercising Tracking is used to raise awareness of behavior patterns and to identify faulty eating and activity patterns. Self monitoring involves observing and recording all eating and exercise behaviors, and monitoring weight. Self-monitoring records can help catch “slips” that may cause weight to creep back up. In the most basic form, individuals record time, activating event, place and quantity of eating, and activity behaviors. PBRC 2005 Behavior Therapy: Important Concepts 5. Avoiding a Food Chain Reaction Stimulus control techniques are used to modify environment influences that affect eating or activity patterns. This involves learning what cues in life seem to encourage undesired eating and then taking charge to change those cues. PBRC 2005 Behavior Therapy: Important Concepts Techniques that help people conquer their eating triggers include: eating regular meals without skipping eating at the same time and place changing serving and food storage techniques (use smaller plates to make portions look bigger) keeping accessible food out of sight eating only when hungry avoiding activities that encourage eating (like watching television). PBRC 2005 Behavior Therapy: Important Concepts 6. Changing Eating and Activity Patterns Techniques used to modify faulty eating behaviors that may interfere with feeling full or lead to overeating include: slowing pace of eating reducing portion sizes measuring food intake leaving food on plate improving food choices, and eliminating second servings PBRC 2005 Behavior Therapy: Important Concepts Changing Eating and Activity Patterns Exercise can be categorized as either programmed (regularly scheduled times of physical activity for a determined amount of time and intensity) or lifestyle (increasing energy expenditure throughout the day). Lifestyle activity has been associated with weight loss in several studies, and it provides a great alternative for the person who hates to exercise. PBRC 2005 Behavior Therapy: Important Concepts 7. Contingency Management Positive reinforcement (reward) is used to stabilize and increase the maintenance of new eating and activity patterns. An effective reward is one that is immediate, desirable and given based on meeting a specific goal. Rewards can be tangible (a new CD) or intangible (taking time off); however, efforts should be made to eliminate all rewards in the form of food. PBRC 2005 Behavior Therapy: Important Concepts 8. Cognitive Behavioral Strategies Cognitive behavioral strategies combine the traditional behavioral treatment components with emphasis on thinking patterns that may affect eating behaviors. The goal of these strategies is to alter mood, unhelpful beliefs, unrealistic standards and negative evaluations that affect eating patterns. PBRC 2005 Behavior Therapy: Important Concepts 9. Stress Management Stress is a primary predictor of overeating and relapse. Stress management skills include progressive muscle relaxation, diaphragmatic breathing and meditation. The goal of stress management is to reduce arousal and provide distraction from stressful events. PBRC 2005 Drugs for 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 PBRC 2005 Drug Therapy Commonly prescribed drugs for the treatment of obesity include: Phentermine Sibutramine Orlistat PBRC 2005 Phentermine Brand names are Adipex-P, Obenix, Oby-Trim Most commonly prescribed medication for weight loss. Phentermine works by increasing the release of norepinephrine, a neurotransmitter in the brain that decreases appetite. Phentermine has stimulant properties, and it may cause high blood pressure or irregular heat beats. PBRC 2005 Sibutramine The brand name is Meridia Sibutramine induces weight loss primarily through its effects on food intake and to a lesser degree through its effect on metabolic rate. Sibutramine affects serotonin and norepinephrine metabolism in the brain by stimulating satiety at the appetite centers in the brain. Sibutramine use may increase heart rate and blood pressure. Regular blood pressure checkups are encouraged. Sibutramine is not recommended for someone with uncontrolled hypertension, tachycardia or serious heart, PBRC 2005 liver, or kidney disease. Orlistat The Brand name is Xenical Orlistat prevents the digestion of dietary fat. It inactivates an enzyme that is involved with fat digestion called lipase, and about 30 percent less fat is absorbed. There may be oily or fatty stools, an increased frequency of bowel movements, and inability to control bowel movements. Because less fat is absorbed, there is improvement in blood lipids. Since less fat is absorbed, a person may become deficient in fatsoluble vitamins A, D, E and K during the treatment and a multivitamin supplement is recommended. PBRC 2005 Surgical Treatment of Obesity Criteria used for surgical treatment: BMI is 40 or higher. (This is about 100 pounds overweight for men and 80 pounds for women). BMI of 35-39.9 and a serious obesity-related health problem such as: Type 2 diabetes, hypertension, heart disease, or sleep apnea (when breathing stops for short periods during sleep). PBRC 2005 Surgical Treatment of Obesity Gastrointestinal surgery is an option for people who are severely obese and cannot lose weight by traditional means or who suffer from serious obesity-related health problems. The operation promotes weight loss by restricting food intake and, in some operations, by interrupting the digestive process. PBRC 2005 Types of GI surgeries available Restrictive Malabsorptive Combined restrictive/malabsorptive PBRC 2005 Restrictive Operations Purely restrictive operations only limit food intake and do not interfere with the normal digestive process. At first, the pouch,which the doctors create at the top of the stomach, holds about 1 ounce of food and later may stretch to 2-3 ounces. The lower outlet of the pouch is usually about ½ inch in diameter or smaller. This small outlet delays the emptying of food from the pouch into the larger part of the stomach and causes a feeling of fullness. PBRC 2005 Restrictive Operations: Examples 1. Adjustable gastric banding The band can be tightened or loosened over time to change the size of the passage by increasing or decreasing the amount of salt solution which inflates the band. PBRC 2005 Restrictive Operations: Examples 2. Vertical banded gastroplasty. Uses the band and staples to create a small pouch. Not commonly used today. PBRC 2005 Restrictive Operations: Advantages 1. 2. Generally safer than malabsorptive procedures. Adjustable gastric banding is generally done via laparoscopy allowing for smaller incisions, less tissue damage, shorter operation time and hospital stay. Surgeries can be reversed if necessary. Result in few nutritional deficiencies. 3. 4. PBRC 2005 Restrictive Operations: Disadvantages 1. 2. 3. 4. Patients generally lose less weight than patients undergoing malabsorptive procedures. Some patients regain weight by eating high calorie soft foods that easily pass through the opening to the stomach. Others are unable to change their eating habits and do not lose much weight. Successful results depend on the patient’s willingness to adopt a long-term plan of healthy eating and regular physical activity. PBRC 2005 Risks: 1. 2. 3. Restrictive Operations Vomiting, which occurs when the patient eats too much or when the narrow passage into the larger part of the stomach is blocked. Common risk of adjustable gastric banding is breaks in the tubing between the band and the access port, requiring another operation to repair. Between 15-20% of vertical banded gastroplasty patients may have to undergo a second operation for a problem related to the procedure. These risks need to be taken into account by any individual considering the surgery! PBRC 2005 Combined Restrictive/Malabsorptive Operations Restrict both food intake and the amount of calories and nutrients the body absorbs. 1. Roux-en-Y gastric bypass (RGB) A small pouch is created to restrict food intake. A section of the small intestine is then attached to the pouch allowing for food to bypass both the large portion of the stomach, the duodenum, and the first part of the jejunum. PBRC 2005 Combined Restrictive/Malabsorptive Operations 2. Biliopancreatic diversion (BPD) The lower portion of the stomach is removed and the small pouch that remains is connected directly to the final segment of the small intestine completely bypassing the duodenum and the jejunum Although this procedure leads to weight loss, it is used less often than other types of operations because of the high risk for nutritional deficiencies. PBRC 2005 Combined Operations: Advantages 1. 2. 3. 4. Rapid weight loss continues 18-24 months after procedure. With Roux-en-Y procedure, many patients maintain a weight loss of 60-70% of their excess weight for 10 years or more. With bilopancreatic diversion, there has been reported an average weight loss of 75-80% of excess weight. May be more effective at improving health problems associated with severe obesity because of the greater weight losses observed when compared to just restrictive surgeries. PBRC 2005 Combined Operations: Disadvantages 1. 2. 3. 4. 5. 6. More difficult to perform than restrictive surgeries. More likely to result in long-term nutritional deficiencies. Decreased absorption of iron and calcium since the duodenum and jejunum are bypassed from the surgery. Patients undergoing BPD operation require fat soluble vitamin supplementation and life-long use of special foods and medications. Dumping syndrome is likely to occur with these procedures after ingestion of a meal high in simple carbohydrates. Nausea, bloating, abdominal pain, weakness, sweating, faintness, and sometimes diarrhea are observed with dumping syndrome. PBRC 2005 Combined Operations: Risks 1. 2. 3. More likely to lead to complications than the restrictive surgeries. Greater risk than restrictive operations for abdominal hernias (up to 28%), which require a follow up to correct. The risk of death associated with these procedures is less than 1% for gastric bypass and around 2.55% in biliopancreatic diversion with duodenal switch operation. PBRC 2005 GI or “Bariatric” Surgeries: Facts Procedures cost from $20,000 to $35,000. Medical insurance coverage varies by state. PBRC 2005 (National Institute of Diabetes and Digestive and Kidney Diseases) NIDDK The patient should consider the following questions prior to weight loss surgery: 1. 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? 2. 3. PBRC 2005 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? PBRC 2005 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. PBRC 2005 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 individual’s decision to go along with the treatment or not. PBRC 2005 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 cognitivebehavior therapy in patient management? Obes Res, 6(Supplement 1), 18S22S 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 PBRC 2005 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: PBRC 2005 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): 26370. Heal DJ, Aspley S, Prow MR, et al. Sibutramine: a novel anti-obesity drug. A review of the pharmacological evidence to differentiate it from damphetamine and d-fenfluramine. Int J Obes Relat Metab Disord 1998 Aug; 22 Suppl 1: S18-S29. PBRC 2005 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. PBRC 2005 References: Exercise http://www.cdc.gov Ross R, Jansses I, Dawson J, Kungl A-M, Kuk JL, Wong SL, Nguyen-Day TB, Lee SL, Kilpatrick K, Hudson R. Exercise induced reduction in obesity and insulin resistance in women: a randomized controlled trial. Obesity Research 12:789-798, 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. PBRC 2005 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 Aug;134(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 Aug;13(Suppl):S146. http://www.slim-fast.com/plan/index.asp?bhcp=1 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. PBRC 2005 Pennington Biomedical Research Center Division of Education Heli J. Roy, PhD, RD Shanna Lundy, BS Phillip Brantley, PhD, Director PBRC 2005