In this presentation we will discuss various treatments for obesity. Obesity has been established as a major risk factor for diabetes, hypertension, cardiovascular disease and some cancers in both men and women. Other comorbid conditions include sleep apnea, osteoarthritis, infertility, idiopathic intracranial hypertension, lower extremity venous stasis disease, gastro-esophageal reflux, and urinary stress incontinence. Deaths from Obesity: 300,000 premature deaths associated with obesity annually (CDC) Death rate extrapolations for USA for Obesity: 300,000 per year, 25,000 per month, 5,769 per week, 821 per day, 34 per hour, 0 per minute, 0 per second. Deaths information for Obesity: Approximately 280,000 adult deaths in the United States each year are attributable to obesity NIDDK _ Statistics Related to Overweight and Obesity: NIDDK)
It is important to consider the following questions before beginning a treatment program for obesity: When does obesity threaten the health and life of a patient? Is the degree of obesity such magnitude that the patient’s life is threatened? Which patients have co-morbidities that make an aggressive treatment necessary? Does the patient have heart disease, hypertension, diabetes, or any other chronic condition?
It is important to assess the patients’ Body Mass Index before beginning any kind of treatment program. There are several different measures used to evaluate a patient's weight status and potential health risk. However, a complete evaluation includes assessments of a person's age, height and weight, fat composition and distribution, and the presence or absence of other health problems and risk factors. Body mass index (BMI) is an easy assessment of obesity. BMI is the body weight in kilograms divided by the square of the height in meters ([weight in kg] ÷ [height in meters] 2). BMI does not actually measure body fat, but generally correlates well with the degree of obesity.
The categories of obesity developed by the World Health Organization are: BMI 25 to 29.9 - Grade 1 obesity (moderate overweight) BMI 30 to 39.9 - Grade 2 obesity (severe overweight) BMI > 40 - Grade 3 obesity (massive/morbid obesity). Example: Using a BMI table, a person 5'6" tall weighing 140 pounds would have a BMI of 23, well out of the range of risk. That same 5'6" person weighing 190 pounds would have a BMI of 31, in the range of Grade 2 obesity. A BMI between 25 and 27 is considered a warning sign and may warrant intervention, especially in the presence of additional risk factors. Treatments to use at this point are dietary counseling, exercise counseling, and behavioral treatment. A BMI of 27 or higher is associated with increased morbidity and mortality; this is generally considered the point at which some form of treatment for obesity is required. At this point, dietary counseling by a registered dietitian is suggested and behavioral counseling by a psychologist are the ideal methods of treatment. More aggressive treatments are not warranted unless there are other co-morbidities present. At BMI above 30, more aggressive treatment options can be considered, such as drug treatment, particularly in the presence of other risk factors. Determine if the patient has any exclusions that are contraindicated for weight loss: pregnancy, mediations, mental illness etc.
There are conditions under which weight loss is contraindicated: osteoporosis, low BMI, history of mental illness and certain medications. If there is any history of anorexia nervosa, weight loss is not recommended. Also if the patient has terminal illness. Determining your patients’ readiness for behavior change is essential for success. Initiating change when patients are not ready often leads to frustration and may hamper future efforts. In fact, the common cycle of failure and renewed effort that is so endemic to weight loss has been described as the “false hope syndrome,” in which patients mistakenly attribute their lack of success to either a failure of effort (low willpower) or a poorly-conceived diet. These faulty assumptions lead patients to fruitlessly search for “a better diet” or to vainly “work harder” the next time. The result is a vicious cycle of self-blame and weight cycling (AMA). Use targeted questions: • “ What is hard about managing your weight?” This open-ended empathic question readily acknowledges that weight control is difficult and conveys an interest for further understanding. • “ How does being overweight affect you?” This question probes the burden of obesity. Common answers refer to appearance, self-esteem and image, physical ailments, and quality-of-life issues. • “ What can’t you do now that you would like to do if you weighed less?” This question provides useful information regarding expectations and benchmarks for assessing progress. • “ What would you like to get out of this visit regarding your weight?” This question directly addresses patients’ expectations related to how you can assist them in weight management.
What kind of treatment is appropriate? Although dietary and physical activity management are the first line of treatment for many patients, pharmacotherapy, and surgery are appropriate at higher BMI’s.
What type of weight management goals should one have? A three-stage approach to weight management should be considered, depending on the patients’ risk status, abilities and desires, and the availability of resources. Stage 1: Prevention of further weight gain This should be considered for patients with low risk status who are currently prepared to make only minor behavior changes. Although prevention of weight gain still requires lifestyle modifications, it may appear less threatening and more achievable than setting weight loss goals. Stage 2: A reduction in body weight of 5% to 10% This should be considered for patients with low to moderate risk status who are committed to making specific behavior changes for weight loss. For most of these patients, a 5% to 10% weight loss is consistent with a loss of 1 to 2 lb/week over 6 months. Not only is this realistic and achievable, but a 10% weight loss can also significantly decrease the severity of obesity-associated risk factors. Stage 3: Maintenance of weight loss After attaining their goal weight, patients should continue lifestyle modifications for the long-term maintenance of their goal weight.
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. For more information: http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/fd_exch.htm An example from the exchange list: Vegetables contain 25 calories and 5 grams of carbohydrate. One serving equals: 1/2 cup Cooked vegetables (carrots, broccoli, zucchini, cabbage, etc.), 1 cup Raw vegetables or salad greens, 1/2 cup Vegetable juice Fat-Free and Very Lowfat Milk contain 90 calories per serving. Very Lean Protein choices have 35 calories and 1 gram of fat per serving. Starches contain 15 grams of carbohydrate and 80 calories per serving.
Foods are within 6 categories. Within each group, these foods can be exchanged for each other. An example from the exchange list: Starches contain 15 grams of carbohydrate and 80 calories per serving. One serving equals: 1 slice Bread (white, pumpernickel, whole wheat, rye), 2 slice Reduced calorie or "lite" Bread, 1/4 (1 Ounce) Bagel (varies), ½ English muffin, ½ Hamburger bun Very Lean Protein choices have 35 calories and 1 gram of fat per serving. Lean Protein choices have 55 calories and 2-3 grams of fat per serving. Medium Fat Proteins have 75 calories and 5 grams of fat per serving. Vegetables contain 25 calories and 5 grams of carbohydrate. One serving equals: 1/2 cup Cooked vegetables (carrots, broccoli, zucchini, cabbage, etc.), 1 cup Raw vegetables or salad greens, 1/2 cup Vegetable juice Fruits contain 15 grams of carbohydrate and 60 calories. Fat-Free and Very Lowfat Milk contain 90 calories per serving. Fats contain 45 calories and 5 grams of fat per serving.
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 .
The table shows the number of each food group at each calorie level. Skim milk is preferred at low calorie levels, while 2% milk is preferred at a higher calorie levels.
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.
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.
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.
This is a recommended schedule for using meal replacers. Meal replacers are recommended for breakfast, if one meal, or breakfast and lunch if two meals, followed by a sensible dinner. It is recommended that people use fruits and vegetables for snacks.
The 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.
Maintaining, gaining, and losing weight are tied to Energy Balance . Maintaining weight means that an energy balance has been reached. Positive energy balance leads to weight gain. Negative energy balance leads to weight loss. Physical activity and caloric intake balance each other out when an individual is at weight maintenance.
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.
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.
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. EXAMPLES Brisk walking Jogging Bicycling Swimming Aerobic dancing Racket sports Lawn mowing Ice or roller skating Using aerobic equipment (treadmill, stationary bike
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.
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.
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
Widely used strategy for weight loss in overweight and obese individuals Based on adjusting energy balance to lower than before to meet ideal body weight calorie needs Individual treatment or Group Format (Ideally should be about 18-24 weeks for adequate support and formulating new habits) One of the most successful ways of treating obese individuals to lose weight with significant chance of them being able to maintain their weight loss
Groups offer Social support which is important in teaching new skills in social situations integration into social network and positive interactions with others. Individual feels support, acceptance, and encouragement by others. It is the social support that makes some of the better weight loss programs work.
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.
Weight is a result of total energy intake minus total energy expenditure. Total energy intake is all the food we consume and activity is every activity from waking until we go to sleep, and including sleep. We can modify what we eat (type of food, food preparation, portion sizes) and we can modify our activity level (whether or not we exercise).
Important Components of Behavior Therapy are 1. making lifestyle change a priority and 2. establishing a plan for success. . Making Lifestyle Change a Priority Making changes to last a lifetime is a difficult thing to do. Important to make health a top priority. It is impossible to be successful unless it is a priority. It cannot be a secondary thing in one’s life. 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. It is important to have a plan and dates for determining success towards goals, otherwise it will not happen. The plan must be written down.
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.
. 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.
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.
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).
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 eliminating second servings
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.
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.
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
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.
Drug treatment of obesity is indicated when: BMI is greater than 30 BMI is higher than 27 and there are other cardiovascular complications When someone has attempted weight loss by diet but After several attempts diet alone is not enough Cardiovascular complications include : Hypertension, Dyslipidemia, Coronary Heart Disease, Type 2 Diabetes, and Sleep Apnea
These are commonly used drugs to treat obesity currently: Phentermine Sibutramine Orlistat. All of these drugs have side effects.
Brand names of Phentermine 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.
Sibutramine brand name is Meridia. It is a widely used weight loss drug. 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, liver, or kidney disease.
Orlistat is actually available over the counter as Alli. 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 fat-soluble vitamins A, D, E, and K during the treatment and a multivitamin supplement is recommended.
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). 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.
Types of GI surgeries available: Restrictive Malabsorptive Combined restrictive/malabsorptive
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
Types of restrictive operations available are: Adjustable gastric banding. A clamp is placed at the upper part of the stomach to create a small pouch. 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. This type of surgery is reversible because nothing is removed or cut and the band can be removed.
Another type of restrictive operation is Vertical banded gastroplasty. This also creates a small pouch with a band and staples. It was used in the early phases of bariatric surgeries, but is not used a lot today because of complications such as infection from the staples.
The benefits of restrictive operations are that they are: 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.
Disadvantages of restrictive operations are: 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.
Some of the risks of restrictive operations are: 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!
Restrict both food intake and the amount of calories and nutrients the body absorbs. 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.
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.
The advantages of the combined operation are 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.
Some of the disadvantages of the combined surgeries are: 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.
Some of the risks of combined operations are: 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 2.5-5% in biliopancreatic diversion with duodenal switch operation.
In terms of cost, it varies from state to state and from hospital to hospital. Insurance coverage as well varies among carriers. The procedure is expensive and results in complete change in life. The person has to be very regimented with supplement intake for the rest of his or her life.
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?
Publication # 11Treatment of Obesity Pennington Biomedical Research Center Division of Education
Treatment options When does obesity threaten the health and life of a patient? Which patients have co-morbidities that make an aggressive treatment necessary? 2012 2
Steps in determining treatment Determine BMI. Assess complications and risk factors 2012 3
Steps in determining treatment Determine BMI-related health risk Determine weight reduction exclusions Mental illness Unstable medical condition Some medications Temporary Pregnancy or lactation 2012 4
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 2012 5
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 2012 6
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. 2012 7
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. 2012 8
Dieting with the Exchange List Foods are divided into 6 categories: Starch/Bread Meat Vegetables Fruit Milk Fat 2012 9
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. 2012 10
Example of daily exchange diet: 1800Kcals daily BREAKFAST 1 c orange juice 2 Fruits 2 slices of toast 2 Breads 1 hard-cooked egg Yields 1 Meat 2 tsp margarine 2 Fat 1 c 2% milk 1 Milk Coffee or tea Free Food 2012 12
Example of daily exchange diet: 1800Kcals daily LUNCH ½ c tuna 2 Meat 2 slices whole wheat bread 2 Bread ½ c tomato slices 1 Vegetable Lettuce/cucumber salad Raw Vegetable Yields 1 c sliced peaches 2 Fruit 1 tsp margarine 2 Fat Tea with lemon Free Foods 2012 13
Example of daily exchange diet: 1800Kcals daily 3 oz baked chicken DINNER 3 meat ½ c mashed potato 1 Bread 1 small whole grain roll 1 Bread ½ c broccoli, ½ c carrots 1 Vegetable Yields Tossed salad Raw Vegetable 1 Tbsp salad dressing 1 Fat 1 tsp margarine 1 Fat Coffee Free Food 2012 14
Example of daily exchange diet: 1800Kcals daily EVENING SNACK 2 graham crackers 1 Bread 1 c 2% milk 1 Milk 2012 15
The Exchange Diet For more information please visit: http://www.diabetes.org/home.jsp 2012 16
Dieting Using Calorie ControlledPortions 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 2012 17
Meal Replacement Plan 4 types of meal replacers: Powder mixes Shakes Bars Prepackaged Meals 2012 18
Meal Replacement Plan An intake of five fruits and vegetables is recommended. Effective Convenient Nutritionally balanced 2012 19
Example:A 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 2012 20
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 2012 21
Exercise Energy Balance = maintaining weight. Positive energy balance leads to weight gain. Negative energy balance leads to weight loss. 2012 22
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. 2012 23
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. 2012 24
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 Racket sports Swimming Lawn mowing Aerobic dancing Ice or roller skating Using aerobic equipment (treadmill, stationary bike) 2012 25
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. 2012 26
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. 2012 27
VLCD: Facts Not recommended for pregnant or breastfeeding women Not appropriate for children or adolescents Not recommended for older individuals 2012 28
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 2012 29
Group Approaches Social support integration into social network and positive interactions with others. Individual feels support, acceptance, and encouragement by others. 2012 30
Behavior Treatment Need to change one’s approach thinking feelings actions to eating and physical activity. 2012 31
Behavioral targets Total energy _ Total energyWeight = intake expenditure Eating Activity Targets of behavioral therapy 2012 32
Behavior Therapy:Important Components 1. Making Lifestyle Change a Priority 2. Establishing a Plan for Success 2012 33
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. 2012 34
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. 2012 35
Behavior Therapy:Important Concepts 5. Avoiding a Food Chain Reaction Stimulus control. Learning to recognize cues. 2012 36
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 2012 37
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 2012 38
Behavior Therapy:Important Concepts Changing Eating and Activity Patterns Programmed exercise vs lifestyle Lifestyle activity preferable for weight loss. 2012 39
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 2012 40
Behavior Therapy:Important Concepts 8. Cognitive Behavioral Strategies Traditional behavioral treatment components with emphasis on thinking patterns that may affect eating behaviors. 2012 41
Behavior Therapy:Important Concepts 9. Stress Management Stress is a primary predictor of overeating and relapse. Stress management skills 2012 42
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 2012 43
Drug Therapy Commonly prescribed drugs for the treatment of obesity include: Phentermine Sibutramine Orlistat 2012 44
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. 2012 45
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. 2012 46
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. 2012 47
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 2012 48
Types of GI surgeries available Restrictive Malabsorptive Combined restrictive/malabsorptive 2012 49
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. 2012 50
Restrictive Operations: Examples 1. Adjustable gastric banding A band is clamped to create a pouch. 2012 51
Restrictive Operations: Examples 2. Vertical banded gastroplasty. Uses the band and staples to create a small pouch. Not commonly used today. 2012 52
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. 2012 53
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 patient’s willingness to adopt a healthy lifestyle. 2012 54
Restrictive Operations: Risks 1. Overeating can lead to vomiting. 2. Break in tubing. 3. Problems leading to a second operation. These risks need to be taken into account by any individual considering the surgery! 2012 55
Malabsorptive Operations The main malabsorptive operation is the jejunoileal bypass which is not performed today because of the high incidence of health complications. 2012 56
Combined Restrictive and MalabsorptiveOperations 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. 2012 57
Combined Restrictive andMalabsorptive Operations Biliopancreatic diversion (BPD) Remove portion of stomach. Connect this directly to the final segment of the small intestine completely bypassing sections of intestines. 2012 58
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. 2012 59
Combined Operations: Disadvantages 1. Can be difficult. 2. May result in long-term nutritional deficiencies. 3. Decreased absorption of iron and calcium. 4. Requires fat soluble vitamin supplementation. 5. May have dumping syndrome. 2012 60
Combined Operations: Risks 1. May lead to complications. 2. Greater risk for abdominal hernias. 3. The risk of death may be higher. 2012 61
Bariatric Surgery: Facts Procedures cost from $17,000 to $35,000. Medical insurance coverage varies by state. 2012 62
NIDDK(National Institute of Diabetes and Digestive and KidneyDiseases) 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? 2. Are you well informed about the surgical procedure and the effects of treatment? 3. Are you determined to lose weight and improve your health? 2012 63
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? 2012 64
Conclusions When there are no complications or co- morbidities associated with obesity, dietary, exercise and behavioral approaches are the safest and best approaches and can lead to long term successful weight loss. For successful weight loss to become permanent, an individual has to adopt new and permanent eating and exercise behaviors. 2012 65
Conclusion It is very important for individuals considering 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 whether to go along with the treatment. 2012 66
References: Behavior Therapy andVLCD 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 2012 67
References : Behavior therapy Poston, W.S.C., Jr., Hyder, M.L., OByrne, 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: 2012 68
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. 2012 69
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. 70 2012
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 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. 2012 71
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. 2012 72
Pennington Biomedical Research Center Division of Education Heli J. Roy, PhD, RD Beth Kalicki Division of Education Phillip Brantley, PhD, Director Pennington Biomedical Research Center Steven Heymsfield, MD, Executive Director 2012 73
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, Alzheimer’s 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. 2012 74