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Treatment of obesity

Treatment of obesity






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    Treatment of obesity Treatment of obesity Presentation Transcript

    • 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
    • Exchanges for Various Calorie LevelsTotalKcal/d 1200 1400 1500 1600 1700 1800 2000 2100 2200Meat 4 4 5 6 6 6 6 6 6Bread/starch 5 7 7 7 8 9 10 11 11Vegs 2 3 4 2 2 2 2 2 3Fats 3 3 3 3 3 4 4 4 4Fruit 3 3 3 3 3 3 3 3 4Skimmilk 2 2 2 - - - - - -(cups)2%milk 2 2 2 2 2 3 2012 11
    • 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