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					  Consequences of Obesity
Hippocrates recognized that
“sudden death is more common in
those who are naturally fat than in
Management of

Increased risk of:

Hypertension             Dyslipidemia
Type 2 diabetes          Stroke
Coronary heart disease   Osteoarthritis
Gallbladder disease
                         Sleep apnea
Certain cancers
Metabolic Features of Obesity
   Hyperinsulinemia - Insulin secretion is
   increased in direct relationship to the
   degree of excess fat
   Increased triglyceride secretion
    VLDL
    HDL
   Insulin resistance
   – Skeletal muscle
   – Fat cells
   Fatty liver may develop
Benefits of Modest Weight Loss
      Decreased Levels of:
     – Glucose
     – Insulin
     – Glycated Hemoglobin
     – LDL Cholesterol
     – Blood Pressure
     – Uric Acid Levels

      Levels of
     – HDL Cholesterol
     Improved Quality of Life
          LOSS in patients w HYPERTENSION

      Each kg of weight loss lowers blood
      pressure by 2.5 mm Hg (systolic) and 1.7
      mm Hg (diastolic)

      Antihypertensive medications reduced or
      discontinued in many patients with
      moderate weight loss

Schotte et al. Arch Intern Med. 1990;150:1701-1704.
        Increased life expectancy1
         – 1kg weight loss increased survival by 3 to 4
         – A 10 kg weight loss could restore 35% of the
           reduction in life expectancy

        Improved glycaemic control2
         – Weight loss of >6.9 kg or >5% of baseline body
           weight improved glucose and HbA1
         – Weight loss predicted fasting blood glucose
 1. Lean et al. Diabet Med. 1989;7:228-233. 2. Wing et al. Arch Intern Med. 1987;147:1749-1753.

                     Every 1-kg decrease in body weight
                     is associated with1:
                      1.93 mg/dL total cholesterol
                      0.77 mg/dL LDL cholesterol
                      1.33 mg/dL triglycerides

                     A loss of 5 kg is associated with2:
                      16% total cholesterol
                      12% LDL cholesterol
                      18% HDL cholesterol
  1. Dattilo et al. Am J Clin Nutr. 1992;56:320-328. 2. Seim et al. Fam Pract Res J. 1992;12:411-419.
Primary goal of obesity
treatment is to improve
   the patient’s health

Legitimate, chronic disease1
 • Serious health
   consequences                                                    Multiple causes2
 • Major risk factor for
                                                            • Genetic, hormonal,
   common causes of death
                                                            • Blaming patient is
                                                              inappropriate and does not
          Treatment options3                                  produce positive outcomes
        • Lifestyle modifications
           • Nutrition/diet
           • Physical activity
           • Behaviour modification
        • Pharmacotherapy
        • Surgery

  1. Clinical guidelines. National Heart, Lung, and Blood Institute Web site. Available at:
  http://www.nhlbi.nih.gov/nhlbi/cardio/obes/prof/guidelns/ob_gdlns.htm. Accessed July 31, 1998.
  2. Weighing the Options; 1995:52. 3. Beales et al. PharmacoEconomics. 1994;5(suppl 1):18-32.
Strategies for Weight Loss and
    Dietarytherapy
    Physical activity
    Behavior therapy
    “Combined” therapy
    Pharmacotherapy
    Weight loss surgery
Goals of Weight

      Prevent further weight gain
       (minimum goal).
      Reduce body weight.
      Maintain a lower body
       weight over long term.
  Target Weight: Realistic Goals
• Substitute “healthier weight” for ideal or
  landmark weight.
• Accept slow, incremental progress to goal.
   — Short-term goal: 5 to 10 percent loss,
      1 to 2 lb per week.
   — Interim goal: Maintenance.
   — Long-term goal: Additional weight
      loss, if desired, and long-term weight
 Weight Loss Goals

Goal: Decrease body weight by 10
  percent from baseline.
 If goal is achieved, further weight
  loss can be attempted if indicated.
 Reasonable timeline: 6 months of
   – Moderate caloric deficits
   – Weight loss 1 to 2 lb/week
    Weight Loss Goals

 Start weight maintenance efforts after
  6 months.
   – May need to be continued
 If unable to lose weight, prevent
  further weight gain.
   Weight Loss Therapy

Whenever possible, weight loss therapy
should employ the combination of
• Low-calorie/low-fat diet
• Increased physical activity
• Behavior modification
Clinical Guidelines on the Identification,
Evaluation, and Treatment of
Overweight and Obesity in Adults

         NHLBI Obesity Education
         National Heart, Lung, and Blood
         in cooperation with the
         National Institute of Diabetes and
         Digestive and Kidney Diseases
         National Institutes of Health
Literature Search
   Systematic review of published
    scientific literature in MEDLINE from
    1980 through September 1997.
   English language.
   Priority: randomized controlled
    trials - 394 reviewed.
   No editorials, letters, or case
    Inclusion and Exclusion Criteria

   Time frame of the study - at least 4

   For long-term maintenance - 1 year or

   Excluded studies with self-reported
    weights, patients not overweight,
    dropout rate >35%, or no appropriate
How Were the Guidelines Developed?

• NHLBI/NIDDK convened a 24-member expert panel
  in May 1995.
• Panel reviewed published scientific literature from
  January 1980 to September 1997. Evidence from 394
  randomized controlled trials (RCTs) was considered.
• Data from 236 RCTs were abstracted, and data were
  compiled into evidence tables.
• Evidence statements and recommendations were
  categorized by level of evidence from A to D.
Purpose of the Guidelines
• To provide a thorough review of the
  scientific evidence on the effects of
  treatment of overweight and obesity

• To provide assistance to primary care
  practitioners on the identification,
  evaluation, and treatment of
  overweight and obese patients
Charge to the Panel
   Examine the scientific evidence regarding
    the issues pertaining to overweight and
    obesity in adults, particularly those issues
    related to:

     — other heart disease risk factors, such as
       hypertension, blood lipid levels, and

     — the distribution and amount of body fat as it
       influences risk;

     — the independent relationship of obesity to
       coronary heart disease (CHD); and,
Charge to the Panel (continued)

     Develop clinical practice
      guidelines, based on the
      evidence, for the practicing
      physician and other health care
      providers who are dealing with
      the problem of overweight in the
      high-risk adult.

     Make guidelines concise,
      comprehensive, and easy to use.
Criteria To Evaluate the

    A — Strong evidence: Evidence from well-
     designed randomized controlled trials (or
     trials that depart only minimally from
     randomization) that provides a consistent
     pattern of findings.

    B — Suggestive evidence (from
     randomized studies): Evidence as in A,
     but involving a smaller number of studies
     and/or a less consistent pattern of
Criteria To Evaluate the Evidence

    C — Suggestive evidence (from
     nonrandomized studies): Evidence from
     the panel’s interpretation of uncontrolled
     or observational studies.

    D — Expert judgment: Evidence from
     clinical experience or experimental
Dietary Therapy          (1 of 5)

Low-calorie diets (LCD) are recommended for
weight loss in overweight and obese persons.
Evidence Category A.

Reducing fat as part of an LCD is a practical
way to reduce calories. Evidence Category A.
Dietary Therapy          (2 of 5)

Low-calorie diets can reduce total body
weight by an average of 8 percent and help
reduce abdominal fat content over a period of
6 months. Evidence Category A.
Dietary Therapy           (3 of 5)

Although lower fat diets without targeted calorie
reduction help promote weight loss by producing
a reduced calorie intake, lower fat diets coupled
with total calorie reduction produce greater
weight loss than lower fat diets alone.
Evidence Category A.
Dietary Therapy          (4 of 5)

Very low-calorie diets produce greater initial
weight loss than low-calorie diets. However,
long-term (>1 year) weight loss is not different
from an LCD. Evidence Category A.
Dietary Therapy          (5 of 5)

 Very Low-Calorie Diets (less than 800
  •   Rapid weight loss
  •   Deficits are too great
  •   Nutritional inadequacies
  •   Greater weight regain
  •   No change in behavior
  •   Greater risk of gallstones
Low-Calorie Step I Diet
Nutrient      Recommended Intake
Calories      500 to 1,000 kcal/day reduction
Total Fat     30 percent or less of total
SFA           8 to 10 percent of total calories
MUFA          Up to 15 percent of total
PUFA          Up to 10 percent of total
Cholesterol   < 300 mg/day
Low-Calorie Step I Diet            (continued)

Nutrient       Recommended Intake
Protein        ~ 15 percent of total calories
Carbohydrate   55 percent or more of total
Sodium Chloride No more than 100 mmol/day (~
                2.4 g of sodium or ~ 6 g of
                sodium chloride)
Calcium        1,000 to 1,500 mg
Fiber          20 to 30 g
Low-Calorie Step I Diet                (continued)

 A reduction in calories of 500 to 1,000 kcal/day
  will help achieve a weight loss of 1 to 2

   Alcohol provides unneeded calories and
    displaces nutritious foods. The impact of
    alcohol calories on a person’s overall calorie
    intake needs to be assessed and appropriately
Low-Calorie Step I Diet (continued)
Total Fat
 Fat-modified foods may provide
  a helpful strategy for lowering
  total fat intake, but are effective
  only if
  – Low in calories
  – No compensation of calories
    from other foods.
Low-Calorie Step I Diet (continued)
Saturated Fatty Acids and
Patients with high blood cholesterol levels
 May need to use the Step II diet to
  achieve further reductions in LDL-
  cholesterol levels;
 In the Step II diet, reduce saturated
  fats to less than 7 percent of total
  calories and cholesterol levels to less
  than 200 mg/day.
 All other nutrients are the same as in
 Low-Calorie Step I Diet

Protein should be derived from
 Plant sources

 Lean sources of animal
Low-Calorie Step I Diet (continued)
Carbohydrate and Fiber
Complex carbohydrates from different
vegetables, fruits, and whole grains are
good sources of vitamins, minerals, and
 A diet high in all types of fiber may aid
in      weight management by promoting
satiety at   lower levels of calorie and fat
 Some authorities recommend 20 to 30
grams of     fiber daily, with an upper
     Low-Calorie Step I Diet

 During weight loss, attention should be given
  to maintaining an adequate intake of vitamins
  and minerals.

   Maintenance of the recommended calcium
    intakes of 1,000 to 1,500 mg/day is especially
    important for women who may be at risk of
   Management of Obesity in
Goals of Treatment
 ADA defines goal: weight management =
  attaining best Wt possible in the context
  of overall health.
 Even moderate wt loss is beneficial:
  – Obese who lose 5-10% of initial weight 
    severity of comorbidities
  – 10% wt loss  improved glycemic control, 
    BP, Cholesterol
   Management of Obesity in
Rate and Extent of Weight Loss
 Rate of wt loss mimics starvation response
  – Loss of protein
  – Metabolic aberrations  bradycardia,
    hypotension, dry skin and hair, fatigue,
    constipation, nervous system abnormalities,
    depression, death.
     Management of Obesity in
   Steady wt loss over longer period
    – Favors reduction of fat stores
    – Limits loss of vital protein tissues
    – Avoids sharp decline in RMR
   NIH:
    –  0.5-1 lb/week for BMI 27-35
    –  1-2 lb/week for BMI >35
    –  10% of body weight after 6 months
    – Next 6 months: focus on wt maintenance
Management of Obesity in
   Rates of wt vary even with same
    caloric intake:
    – Men lose wt faster (higher LBM and RMR)
    – Heavier person loses wt faster than
      lighter person (expends more E)
     Management of Obesity in
   Limit alcohol & sugar (unnecessary sources of
   Small amounts can be included for palatability
   Alcohol behaves like fat (spares fat from being
   Artificial sweeteners & fat substitutes may
    improve acceptability
   Vitamin & mineral suppl. if program provides
    <1200 kcal for women or <1800 kcal for men
   Management of Obesity in
Formula Diets & Meal Replacement Programs
 Good programs contain
  – High-quality protein
  – Sugar as fructose
  – Moderate amount of monounsaturated fats
  – 1000-1600 calories/day
  – Drink or bar replace 2 meals (wt loss) or 1 meal
    (wt maintenance) per day.
  – Considered safe
  – 4 year follow-up: sustained improvements
Management of Obesity in
Commercial Programs
 Evaluate programs by comparing with
  sound nutritional practices
 Examples:
  – Prepackaged low-fat meals
  – Classes on self-introspection, behavior
    modification, nutrition
  – Internet
Name                Foods or Products
VLCD Programs
Health Management   Special drink,
Resources           multidisciplinary system
Medifast            Special drink, physician
Optifast            Special drink, physician
Name                   Foods or Products
Diet programs
Diet Center            Regular food
Jenny Craig            Prepackaged foods
Nutri-System           Prepackaged foods
Weight Watchers        Regular food
The Solution           Regular food
Internet-Based Diets
Cyberdiet              Regular food
eDiets                 Regular food
Nutrio                 Regular food
   Management of Obesity in
Extreme Energy Restriction
 Fasting
  – Religious or protest regimens or personal effort
  – Seldom continued long enough to produce
    neurologic, hormonal side effects
  – > 50% of wt loss is fluid  hypotension
  – Accumulation of uric acid  gout
  – Gallstones can occur
     Management of Obesity in
   Very-Low-Calorie Diets
    – 200-800 kcal/d
    – Little evidence as to their advantage
    – High in protein (0.8-1.5g/kg IBW per day)
    – Full complement of vitamins, minerals,
      electrolytes, essential FA
    – 12 – 16 weeks
    – Rapid wt loss
    – Only given to persons with BMI >30
      unsuccessful otherwise
Very low calorie diets

   “Supplemented fasts”
   Liquid formula diets 420-800cal/day
   Protein-sparing modified fast
   BMI >30
   Multi-disciplinary to maintain loss
    – Nutrition, Behavior, Exercise
   Medical supervision
   Contraindicated with disease
Management of Obesity in
   VLCDs – 2 forms:
    1. PMSF (1.5g protein/kg IBW)
         Lean meat, fish, poultry
         No CHO
         Only the fat contained in the protein
         High nitrogen excretion (11-23g/d)
         Add 100g CHO prevents further N loss
    Management of Obesity in
   VLCDs – 2 forms:
    2. Commercially formulated liquid diets
      –   Based on milk or egg protein
      –   33 – 70g protein
      –   30 – 45g CHO
      –   Small amount of fat
      –   400 – 800 kcal/d
      –   20kg in 12 – 16 weeks, 33 – 55% of loss
          maintained after 1 year
      –   Cardiac complications
      –   Loss of K, other electrolytes, body protein
     Management of Obesity in
   VLCDs:
    – urinary ketones  interference with renal
      clearance of uric acid  gout
    – serum cholesterol (mobilization of adipose
      stores)  risk of gallstones
    – Cold intolerance, fatigue, lightheadedness,
      nervousness, euphoria, constipation or
      diarrhea, dry skin, thinning reddened hair,
      anemia, menstrual irregularities
    – 1998 NIH recommendation against VLCDs
    Management of Obesity in
Popular Diets and Practices
 3 categories:
  1. High-fat (55%-65%, low-CHO (<20%)
        Protein from animal sources  sat. fat, chol
        Initial rapid wt loss from diuresis due to CHO
        E.g.: Dr. Atkins’; The CHO Addict’s Diet
        Zone diet: 40% CHO, 30% prot, 30% fat. Claims to
         control insulin, but wt loss is due to calorie restriction
Management of Obesity in
Popular Diets and Practices
2. Moderate-fat, balanced nutrient
  reduction diets
  – 20-30% fat, 15-20% protein, 55-60%
  – E.g.: Volumetrics, focus on E density of
  – Foods with high water content have low E
   Management of Obesity in
Popular Diets and Practices
3. Very-low-fat (<10%) & low-fat (10-19%)
  – E.g.: Dr. Dean Ornish’s Program for Reversing
   Heart Disease; Pritikin Program
  – Rapid wt loss, very restrictive
  – Low-fat + ad lib CHO diet  less wt loss, more
    gradual than low-fat/calorie restricted diet
 Treatment Algorithm
                           Self-Directing Diet and Exercise
                           Physician Counseling
    BMI < 27
                           Commercial Program
                           Behavioral Program
  BMI 27 - 29              Self-Help Program

  BMI 30 - 39              Pharmacotherapy
                           Very-Low-Calorie Diet
                           Residential Programs
   BMI  40
                           Surgery
Preferred Treatment
Less Intensive Option
More Intensive Option
                                         Wadden et al Obes Res. 1997
    Evidence Model for Treatment of Overweight and
                                   Noncardiovascular Mortality and Morbidity
Overweight Individual
                                     Cardiovascular Mortality and Morbidity

                                              Cardiovascular Disease

                                 High Blood        Dyslipidemia            Glucose
                                  Pressure                                Intolerance

                                     Fat              Weight               Fitness

                        Assess          ( Kcal Out)    Treat      (    Kcal In )
    Evidence Model for Treatment of Overweight and
Overweight Individual
                        High Blood                          Glucose
                        Pressure                           Intolerance

                                         Weight           Fitness

               Assess      ( Kcal Out)    Treat         ( Kcal In)
      Management of Obesity in
 LBM  balance loss of LBM & RMR
  reduction caused by wt-reduction
 Strengthen cardiovascular integrity
 Insulin sensitivity
 Combination of aerobic + resistance training
 Resistance training:
    – LBM, Bone mineral density,
   Improved sense of well-being
Management of Obesity in
 Creates E deficit
 Can lower wt by 2 – 3kg even without diet
 Exercisers with hypertrophic obesity lose
  more fat than very obese with hyperplastic
 Some studies show:
  – No  in wt loss but body fat loss
  – Physical exercise muscle mass  body wt may
    not change
  – With continued exercise, net decrease in body
Management of Obesity in
 RMR during exercise, returns to resting
  levels within 1 hour
  due to replacement of muscle glycogen +
  effects of hormonal changes + metabolic
  processing of fuel stores
 Spot reduction (fat in one area of body):
  not possible with exercise
 Recommendations: 1h/day of moderately
  intense activity, or 20-30 min of high-
  intensity activity 4-7 days/week
Physical Activity
Recommended as part of a comprehensive
weight loss therapy and maintenance program
because it:
 • Modestly contributes to weight loss
  Evidence Category A.
 • May decrease abdominal fat
  Evidence Category B.
 • Increases cardiorespiratory fitness
  Evidence Category A.
Increase Physical Activity:
All Energy Expenditure Counts!
    Park farther away
    Walk short distances—walk instead of drive
    Take stairs, walk the mall
    Do more chores
      – Gardening
      – Cleaning
    Effects of increased activity add up: small
     increases result in benefit
    Join health club
    Physical Activity: Impact on

•   Enhances cardiorespiratory fitness
•   Improves lipid profile
•   Reduces blood pressure
•   Increases insulin sensitivity
•   Improves blood glucose control
  Behavioral Therapy
  Readiness to Change

“ Habit is Habit, and Not to be Flung Out
  of the Window, But Coaxed Downstairs
  a Step at a Time. ”
                        Mark Twain
Behavior Therapy

The routine use of behavior therapy strategies
to promote diet and physical activity is
recommended, as these strategies are helpful
in achieving weight loss and weight
Evidence Category B.
Behavior Therapy          (continued)
Implementation of strategies, based on
learning principles, that provide tools for
overcoming barriers to compliance with diet
or physical activity changes:
  • Self-monitoring
  • Stress management
  • Stimulus control
  • Problem-solving
  • Contingency management
  • Cognitive restructuring
  • Social support
. . . . . . . . . . Leave
Know the grave doth gape for
Thrice wider than for other men.
                   - Shakespeare
             Henry IV
                 Act V, Scene 5
Common Problems
Encountered in Obesity
   Common Problems
Plateau Effect
 Wt loss results in loss of the extra muscle
  that supported the XS adipose tissue
 LBM   RMR
 Also:  kcal ingested  TEF
 Body weighs less  cost of physical
  activity 
  Equilibrium reached: E intake = E exp
   Wt loss stops
Common Problems

Weight Cycling
 Losing & gaining wt several times

 With each turn of the cycle, it takes
  longer to lose the same amount of wt
 Detrimental to self-esteem, loss of
   Management of Obesity in
Pharmaceutical Management
 Useful in patients with BMI >30 or >27
   + other risk factors
 2 categories:
  1. CNS-acting agents:
       Catecholaminergic agents, serotoninergic agents,
        combination of the 2
       Side effects: dry mouth, headache, insomnia,
FDA Approved
Anti-Obesity Medications
Generic Name                Trade Name
Diethylpropion    Tenuate, Tenuate Dospan
Mazindol          Sanorex, Mazanor
Phendimetrazine   Bontril, Plegine, Prelu-2, X-Trozine
Phentermine       Adipex-P, Fasin, Oby-Trim, Ionamin
Sibutramine       Meridia
Orlistat          Xenical
Management of Obesity in
 1. CNS-acting agents:
 – Catecholaminergic drugs act on brain,
    increasing availability of norepinephrine
      E.g. amphetamines (high potential for
      E.g. phentermine (low potential for abuse
       but blood pressure)
      E.g. phenylpropanolamine (PPA), linked
       with hemorrhagic stroke  discontinued
Management of Obesity in
 1. CNS-acting agents:
 – Serotoninergic agents: increase serotonin levels
    in brain
      E.g.: fenfluramine hydrochloride, dexfenfluramine
       HCl; removed from market (possible cardiac
       valvulopathy & regurgitation, pulmonary
 – Combination of catecholaminergic +
   serotoninergic agents
      E.g. sibutramine (inhibits reuptake of serotonin &
       NE), caution needed with patients with hypertension
   Management of Obesity in
2. Non-CNS-acting agents:
  – Orlistat (Xenical): acts on GI tract to inhibit fat
  – Taken with mildly hypocaloric meals ( 30%
    fat absorption)
  – Fat-soluble vitamins generally remain within
    normal range
  – Side effects: oily spotting, fecal urgency, flatus
    with discharge
  – LDL-C, HDL-C, improved glycemic control, BP
   Management of Obesity in
Pharmaceutical Management
 Not all individuals respond to
 Can expect loss of 1 lb/week

 Most wt loss occurs during the first 6 months

 After medication is stopped, most patients
  regain weight
   Management of Obesity in
Surgical Procedures
 BMI ≥40; or BMI ≥35 with other risk
 Need to demonstrate failure of
  comprehensive program (diet, exercise,
  lifestyle Δ, psychological counseling)
 Failure = inability to body wt by 1/3 &
  body fat by ½; & inability to maintain
  achieved wt loss
   Management of Obesity in
Gastric Restriction (Gastric Bypass & Gastroplasty)
 Capacity of stomach

 Gastroplasty: application of rows of stainless-
  steel staples to partition the stomach, leaving
  small opening into distal stomach
 Gastric bypass: stapling + connecting a small
  opening in upper portion of stomach to small
  intestine (intestinal loop)
for Obesity
Management of Obesity in
Gastric Restriction (Gastric Bypass &
  – amount of food eaten, early satiety
  – New stomach capacity: 20-30ml
  – Safe sustainable results
  – Complications:
        Bloating of the pouch, nausea, vomiting.
  – Postoperative regimen: liquids  solid foods,
    focus on protein intake
  – Attention to vitamins & minerals (esp. Ca, folate,
    Fe, B12)
   Management of Obesity in
Gastric Restriction (Gastric Bypass &
 Dumping Syndrome; symptoms:
  tachycardia, sweating, abdominal pain
 Lifelong follow-up & monitoring

 Monitoring: assess body-fat loss, anemia,
  deficiencies in K, Mg, folate, B12.
   Management of Obesity in
Jaw Wiring (Maxillomandibular Fixation)
 Restricts eating to liquids through a straw

 Oral hygiene is important

 Recommendations for liquids &
  supplements to provide adequate nutrients
 Patient taught how to cut wires & deal with
 Wt regain after wires are removed, without
  education & support
   Management of Obesity in
 Aspiration of fat deposits

 Most successful on younger persons with
  small amounts of fat to be removed
 Not wt-reduction, but cosmetic surgery
  (only 5lb of fat removed at a time)
 Possible consequences: death, severe
  infection cellulitis, hemorrhage
   Management of Obesity in
Maintenance of Reduced Body Weight
 Only 5% of reduced-obese keep from gaining wt
  after 5 years.
 E requirements for maintenance: 25% lower
  than at original wt.
  need to maintain reduced E intake even after
  wt loss.
 Permanent lifestyle modification necessary

 Exercise, support groups

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