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. . Patient BMI. Obesity Management in an Outpatient Office Practice. 37. 29. 33. 21. 40. 31. 27. 20. Establish diagnosis:BMI. BMI = weight (kg)/ [height (M)]2Correlates well with direct measures of adiposityOverweight child: BMI >85th and <95th percentileObese child: BMI > 95th percentileIf child < 3 years old, use weight for height.
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1. Diagnosing and Treating Obesity MMA Task Force on Obesity For information on how to arrange for a presentation on obesity diagnosis and prevention, please contact Lorrie Holmgren, MMA Director of Communications, 612/362-3742 or lholmgren@mnmed.org
2. Obesity Management in an Outpatient Office Practice Obesity management in an outpatient office practice
The marked increase in the prevalence of obesity and the association of obesity with many medical complications have led to a marked increase in the number of obese patients seen in outpatient medical practices. The body mass index (BMI) of each patient sitting in an office waiting room is shown in this photograph. This section reviews the management principles in treating obese patients in an outpatient office practice setting.Obesity management in an outpatient office practice
The marked increase in the prevalence of obesity and the association of obesity with many medical complications have led to a marked increase in the number of obese patients seen in outpatient medical practices. The body mass index (BMI) of each patient sitting in an office waiting room is shown in this photograph. This section reviews the management principles in treating obese patients in an outpatient office practice setting.
3. Establish diagnosis:BMI BMI = weight (kg)/ [height (M)]2
Correlates well with direct measures of adiposity
Overweight child: BMI >85th and <95th percentile
Obese child: BMI > 95th percentile
If child < 3 years old, use weight for height
5. The Wall Street Journal says that this obesity epidemic is nonsense. They say that body weight has been gradually increasing for a century.
6. Ten Year (approx) Change in US Prevalence (NHANES) of Obesity and Severe (BMI > 40) Obesity
8. The New England Journal says that obesity is overstated as a problem and that most people have mild to moderate overweight, which is not medically threatening.
9. Medical Complications of Obesity Medical complication of obesityMedical complication of obesity
10. Complications of Childhood obesity
11. Relationship Between Weight Gain in Adulthood and Risk of Type 2 Diabetes Mellitus Relationship between weight gain in adulthood and risk of type 2 diabetes mellitus
An increase in weight since young adulthood (1820 years of age) in men and women is associated with increased risk of developing type 2 diabetes. A weight gain of 10 kg, which is the average amount of weight gained by US adults from 20 to 50 years of age, is associated with a two- to threefold increase in the risk of diabetes. Weight gain during adulthood is also associated with an increased risk of coronary heart disease, hypertension, and cholelithiasis compared with those who maintain their weight after 18 to 20 years of age.
Willet WC, Dietz WH, Colditz GA. Guidelines for healthy weight. N Engl J Med 1999;341:427-434.Relationship between weight gain in adulthood and risk of type 2 diabetes mellitus
An increase in weight since young adulthood (1820 years of age) in men and women is associated with increased risk of developing type 2 diabetes. A weight gain of 10 kg, which is the average amount of weight gained by US adults from 20 to 50 years of age, is associated with a two- to threefold increase in the risk of diabetes. Weight gain during adulthood is also associated with an increased risk of coronary heart disease, hypertension, and cholelithiasis compared with those who maintain their weight after 18 to 20 years of age.
Willet WC, Dietz WH, Colditz GA. Guidelines for healthy weight. N Engl J Med 1999;341:427-434.
12. ATP III: the metabolic syndrome
The NCEP ATP III guidelines define 5 components of the metabolic syndrome; 3 or more risk factors are required for the diagnosis of the metabolic syndrome. The low HDL-C criterion for women is higher than that defined for risk factor counting in the ATP III algorithm for primary prevention, and the blood pressure criterion is lower. A comparison of the ATP III risk factorcounting algorithm and the metabolic syndrome is given in the next two slides.
Reference:
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497.ATP III: the metabolic syndrome
The NCEP ATP III guidelines define 5 components of the metabolic syndrome; 3 or more risk factors are required for the diagnosis of the metabolic syndrome. The low HDL-C criterion for women is higher than that defined for risk factor counting in the ATP III algorithm for primary prevention, and the blood pressure criterion is lower. A comparison of the ATP III risk factorcounting algorithm and the metabolic syndrome is given in the next two slides.
Reference:
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497.
13. Increase in Healthcare Costs Among Obese Compared with Lean (BMI <25 kg/m2) Patients* Increase in healthcare costs among obese compared with lean (BMI <25 kg/m2) patients
Obesity is associated with increased outpatient and inpatient medical costs. This figure shows the relative increase in the cost of healthcare services required by obese compared with lean members of a health maintenance organization (HMO) in northern California. These healthcare services can be divided into three categories: 1) outpatient healthcare visits, outpatient pharmacy services, outpatient laboratory services, 2) total outpatient services, total inpatient services, and 3) total cost of health care. Among the 17,118 members of this HMO, there was a 25% increase in total healthcare costs in those with class I obesity (body mass index [BMI] 30.0-34.9 kg/m2) and a 44% increase in total healthcare costs in those with class II or III obesity (BMI 35 kg/m2 or greater), compared with lean patients (BMI 20.0-24.9 kg/m2). The increased healthcare costs for obese patients was largely a result of costs related to coronary heart disease, hypertension, and diabetes.
Quesenberry CP et al. Obesity, health utilization and health care costs among members of a health maintenance organization. Arch Intern Med. 1998;158:466-472.Increase in healthcare costs among obese compared with lean (BMI <25 kg/m2) patients
Obesity is associated with increased outpatient and inpatient medical costs. This figure shows the relative increase in the cost of healthcare services required by obese compared with lean members of a health maintenance organization (HMO) in northern California. These healthcare services can be divided into three categories: 1) outpatient healthcare visits, outpatient pharmacy services, outpatient laboratory services, 2) total outpatient services, total inpatient services, and 3) total cost of health care. Among the 17,118 members of this HMO, there was a 25% increase in total healthcare costs in those with class I obesity (body mass index [BMI] 30.0-34.9 kg/m2) and a 44% increase in total healthcare costs in those with class II or III obesity (BMI 35 kg/m2 or greater), compared with lean patients (BMI 20.0-24.9 kg/m2). The increased healthcare costs for obese patients was largely a result of costs related to coronary heart disease, hypertension, and diabetes.
Quesenberry CP et al. Obesity, health utilization and health care costs among members of a health maintenance organization. Arch Intern Med. 1998;158:466-472.
14. Doc, I am fat because my hormones are out of whack. I know I dont eat too much. Can you check out whats wrong with me and give me a pill to fix it..
15. Hormonal Causes of Obesity Cushings Syndrome (glucocorticoid excess)
Most treatments for Diabetes Mellitus type 2
NOT Hypothyroidism
Very few (less than 1%) of patients are obese due to hormonal problems, but a substantial number are obese in part due to diabetes treatment or treatment with glucocorticoids
16. Selected Medications That Can Cause Weight Gain Psychotropic medications
Tricyclic antidepressants
Monoamine oxidase inhibitors
Specific SSRIs
Atypical antipsychotics
Lithium
Specific anticonvulsants
?-adrenergic receptor blockers Selected medications that can cause weight gain
Certain medications can cause weight gain and increase body fat, thereby making weight loss more difficult. This table presents a partial list of drugs and drug classes that contain medications associated with weight gain. These drugs differ in their propensity to increase body weight; some medications, such as the anticonvulsant valproic acid, can cause considerable weight gain of 1520 kg, whereas other medications, such as the -adrenergic receptor blocker propranolol, are associated with small and probably clinically insignificant weight gain. The mechanism responsible for medication-induced weight gain has not been carefully studied for most of these agents, but must be related to an increase in energy intake (e.g. antipsychotics and steroid hormones), a decrease in energy expenditure (e.g. -adrenergic receptor blockers), a decrease in energy loss (e.g. decreased glucosuria from diabetes therapy), or a combination of these factors. Weight loss therapy can be facilitated by decreasing the dose or substituting the medication with another drug that has less weight gain potential, if possible.
Pijl H, Meinders AE. Bodyweight changes as an adverse effect of drug treatment. Drug Safety 1996;14:329-342.Selected medications that can cause weight gain
Certain medications can cause weight gain and increase body fat, thereby making weight loss more difficult. This table presents a partial list of drugs and drug classes that contain medications associated with weight gain. These drugs differ in their propensity to increase body weight; some medications, such as the anticonvulsant valproic acid, can cause considerable weight gain of 1520 kg, whereas other medications, such as the -adrenergic receptor blocker propranolol, are associated with small and probably clinically insignificant weight gain. The mechanism responsible for medication-induced weight gain has not been carefully studied for most of these agents, but must be related to an increase in energy intake (e.g. antipsychotics and steroid hormones), a decrease in energy expenditure (e.g. -adrenergic receptor blockers), a decrease in energy loss (e.g. decreased glucosuria from diabetes therapy), or a combination of these factors. Weight loss therapy can be facilitated by decreasing the dose or substituting the medication with another drug that has less weight gain potential, if possible.
Pijl H, Meinders AE. Bodyweight changes as an adverse effect of drug treatment. Drug Safety 1996;14:329-342.
17. Yea, I know about balancing food and activity, but I dont dont eat that much.
I dont eat more than other people
I only eat salads.
18. Discrepancy Between Reported and Actual Energy Intake and Expenditure Discrepancy between reported and actual energy intake and expenditure
A subset of obese patients believe that they are unable to lose weight despite careful adherence to a low-calorie diet (<1200 kcal/d). These patients often assume that a metabolic defect in energy metabolism is responsible for their difficulty in losing weight. This figure shows the results of a study involving 10 patients (1 man, 9 women) who had repeatedly failed to lose weight despite multiple attempts with low-calorie diet therapy [1]. All patients were placed on a low-calorie diet for 14 days. Measures of total daily energy expenditure, by using the doubly-labeled water technique, and self-reported dietary intake were obtained throughout the study. Body composition, measured by hydrodensitometry, was determined at the beginning and end of the study. Actual food intake was calculated from measures of total energy expenditure and changes in body composition. The data demonstrated that these subjects reported good compliance with their diet and activity program, but under-reported their actual energy intake by 47% and over-reported their actual physical activity by 51%.
Lichtman SW, Pisarska K, Berman ER, et al. Discrepancy between self-reported and actual caloric intake and exercise in obese subjects. N Engl J Med 1992;327:1893-1898.Discrepancy between reported and actual energy intake and expenditure
A subset of obese patients believe that they are unable to lose weight despite careful adherence to a low-calorie diet (<1200 kcal/d). These patients often assume that a metabolic defect in energy metabolism is responsible for their difficulty in losing weight. This figure shows the results of a study involving 10 patients (1 man, 9 women) who had repeatedly failed to lose weight despite multiple attempts with low-calorie diet therapy [1]. All patients were placed on a low-calorie diet for 14 days. Measures of total daily energy expenditure, by using the doubly-labeled water technique, and self-reported dietary intake were obtained throughout the study. Body composition, measured by hydrodensitometry, was determined at the beginning and end of the study. Actual food intake was calculated from measures of total energy expenditure and changes in body composition. The data demonstrated that these subjects reported good compliance with their diet and activity program, but under-reported their actual energy intake by 47% and over-reported their actual physical activity by 51%.
Lichtman SW, Pisarska K, Berman ER, et al. Discrepancy between self-reported and actual caloric intake and exercise in obese subjects. N Engl J Med 1992;327:1893-1898.
19. My problem is my metabolism is slow. Anything at all that I eat turns to fat.
20. Relationship Between Resting Energy Expenditure and Fat-free Mass Relationship between resting energy expenditure and fat-free mass
Resting energy expenditure (REE) correlates closely with fat-free mass in lean and obese men and women. Although energy expenditure of metabolically active organs is responsible for a large component of REE, fat free-mass, which is composed primarily of skeletal muscle, accounts for most of the variability in energy expenditure between individuals. This figure demonstrates that both fat-free mass and REE generally are greater in obese than lean persons, but REE follows the same regression line in lean and obese subjects across a wide range of fat-free masses.
Owen O. Resting metabolic requirements of men and women. Mayo Clin Proc 1988;63:503-510.Relationship between resting energy expenditure and fat-free mass
Resting energy expenditure (REE) correlates closely with fat-free mass in lean and obese men and women. Although energy expenditure of metabolically active organs is responsible for a large component of REE, fat free-mass, which is composed primarily of skeletal muscle, accounts for most of the variability in energy expenditure between individuals. This figure demonstrates that both fat-free mass and REE generally are greater in obese than lean persons, but REE follows the same regression line in lean and obese subjects across a wide range of fat-free masses.
Owen O. Resting metabolic requirements of men and women. Mayo Clin Proc 1988;63:503-510.
21. Any time I try to lose weight, my metabolism slows down so much that I cant lose weight.
22. Energy Metabolism Before and After Weight Loss Energy metabolism before and after weight loss
An important clinical question is whether weight loss in obese persons causes an abnormal decline in energy expenditure, which could become an obstacle to long-term successful weight management. The answer to this question is not entirely clear because of conflicting data from different studies. However, the results from most studies support the notion that resting energy expenditure (REE) and total daily energy expenditure (TEE) in reduced-obese subjects are normal for their new body size and composition. This figure represents data from a study that evaluated REE, by use of indirect calorimetry, and free-living TEE, by use of the doubly-labeled water technique, in a group of obese women who lost approximately 25% of their initial body weight (BMI decreased from 31 to 23 kg/m2) and in a never-obese control group [1]. The reduced-obese subjects were studied after they were weight stable for at least 2 months. Although weight loss caused a 10% decline in REE and TEE, the decline in metabolic rate was appropriate for their new body size. Both REE and TEE values in reduced-obese women were the same as those predicted based on the values obtained in the never-obese control group.
Amatruda JM, Statt MC, Welle SL. Total and resting energy expenditure in obese women reduced to ideal body weight. J Clin Invest 1993;92:1236-1242.Energy metabolism before and after weight loss
An important clinical question is whether weight loss in obese persons causes an abnormal decline in energy expenditure, which could become an obstacle to long-term successful weight management. The answer to this question is not entirely clear because of conflicting data from different studies. However, the results from most studies support the notion that resting energy expenditure (REE) and total daily energy expenditure (TEE) in reduced-obese subjects are normal for their new body size and composition. This figure represents data from a study that evaluated REE, by use of indirect calorimetry, and free-living TEE, by use of the doubly-labeled water technique, in a group of obese women who lost approximately 25% of their initial body weight (BMI decreased from 31 to 23 kg/m2) and in a never-obese control group [1]. The reduced-obese subjects were studied after they were weight stable for at least 2 months. Although weight loss caused a 10% decline in REE and TEE, the decline in metabolic rate was appropriate for their new body size. Both REE and TEE values in reduced-obese women were the same as those predicted based on the values obtained in the never-obese control group.
Amatruda JM, Statt MC, Welle SL. Total and resting energy expenditure in obese women reduced to ideal body weight. J Clin Invest 1993;92:1236-1242.
23. So obesity is all genetic. Theres nothing I can do.
24. Gene-Environment Interaction in the Pathogenesis of Obesity Gene-environment interaction in the pathogenesis of obesity
Although genetics is an important factor in the pathogenesis of obesity, the recent increase in obesity cannot be attributed to genetics alone and must be a result of alterations in environmental influences. However, people with certain genetic backgrounds are particularly predisposed to weight gain and obesity-related diseases, especially when they are exposed to a precipitating lifestyle. A striking example of this is given by the Pima Indians of Arizona. Lifestyle changes have resulted in an epidemic of obesity and diabetes within this population during the last 50 years [1]. Today, the Pimas of Arizona consume a high-fat diet (50% of energy as fat) provided by government surplus commodities rather than their traditional low-fat diet (15% of energy as fat), and they are much more sedentary than when they were farmers. In contrast, Pima Indians who live in the Sierra Madre mountains of Northern Mexico, and consequently who have been isolated from Western influences, eat a traditional Pima diet and are physically active as farmers and sawmill workers. The Pimas of Mexico have a much lower incidence of obesity and diabetes than their genetic kindred in Arizona.
Pratley RE. Gene-environment interactions in the pathogenesis of type 2 diabetes mellitus: lessons learned from the Pima Indians. Proc Nutr Soc. 1998;57:175-181.
Ravussin E et al. Effects of a traditional lifestyle on obesity in Pima Indians. Diabetes Care 1994; 17:1067-1074.Gene-environment interaction in the pathogenesis of obesity
Although genetics is an important factor in the pathogenesis of obesity, the recent increase in obesity cannot be attributed to genetics alone and must be a result of alterations in environmental influences. However, people with certain genetic backgrounds are particularly predisposed to weight gain and obesity-related diseases, especially when they are exposed to a precipitating lifestyle. A striking example of this is given by the Pima Indians of Arizona. Lifestyle changes have resulted in an epidemic of obesity and diabetes within this population during the last 50 years [1]. Today, the Pimas of Arizona consume a high-fat diet (50% of energy as fat) provided by government surplus commodities rather than their traditional low-fat diet (15% of energy as fat), and they are much more sedentary than when they were farmers. In contrast, Pima Indians who live in the Sierra Madre mountains of Northern Mexico, and consequently who have been isolated from Western influences, eat a traditional Pima diet and are physically active as farmers and sawmill workers. The Pimas of Mexico have a much lower incidence of obesity and diabetes than their genetic kindred in Arizona.
Pratley RE. Gene-environment interactions in the pathogenesis of type 2 diabetes mellitus: lessons learned from the Pima Indians. Proc Nutr Soc. 1998;57:175-181.
Ravussin E et al. Effects of a traditional lifestyle on obesity in Pima Indians. Diabetes Care 1994; 17:1067-1074.
25. Effect of Meal Variety on Energy Intake Effect of meal variety on energy intake
The variety of palatable foods found in grocery stores, restaurants, and at home facilitates overeating. Several studies [1,2] have shown that the variety of available food can affect the amount eaten. Continued consumption of a single food becomes less pleasant; as palatability decreases, consumption decreases and stops. However, if other foods are also available, particularly those with different sensory properties, they may be eaten because they remain enjoyable. Changes in the pleasantness of foods help explain why meal variety increases food intake. In this study, 48 men and women were offered two different lunches [2]. On one occasion, the subjects were given a four-course lunch with a different food for each course; on the other occasion, they were served four courses of the same food. Total energy intake was 60% greater when the varied meal was provided than when a single food was given.
Rolls BJ, Rowe EA, Rolls ET, et al. Variety in a meal enhances food intake. Physiol Behav 1981;26:215-221.
Rolls BJ, Van Duijvenvoorde PM, Rolls ET. Pleasantness changes and food intake in a varied four-course meal. Appetite 1984;5:337-348.Effect of meal variety on energy intake
The variety of palatable foods found in grocery stores, restaurants, and at home facilitates overeating. Several studies [1,2] have shown that the variety of available food can affect the amount eaten. Continued consumption of a single food becomes less pleasant; as palatability decreases, consumption decreases and stops. However, if other foods are also available, particularly those with different sensory properties, they may be eaten because they remain enjoyable. Changes in the pleasantness of foods help explain why meal variety increases food intake. In this study, 48 men and women were offered two different lunches [2]. On one occasion, the subjects were given a four-course lunch with a different food for each course; on the other occasion, they were served four courses of the same food. Total energy intake was 60% greater when the varied meal was provided than when a single food was given.
Rolls BJ, Rowe EA, Rolls ET, et al. Variety in a meal enhances food intake. Physiol Behav 1981;26:215-221.
Rolls BJ, Van Duijvenvoorde PM, Rolls ET. Pleasantness changes and food intake in a varied four-course meal. Appetite 1984;5:337-348.
26. Effect of Portion Size on Energy Intake Effect of portion size on energy intake
Food portion size affects energy intake. In this study, young adult men and women were served four different portions of macaroni and cheese for lunch on different days, and were allowed to consume as much food as they liked [1]. The data demonstrate a linear relationship between portion size served and intake: increasing the amount of macaroni and cheese served increased the amount that was consumed.
Rolls BJ, Morris EL, Roe LS. Portion size of food affects energy intake in normal-weight and overweight men and women. Am J Clin Nutr 2002 Dec;76(6):1207-13.Effect of portion size on energy intake
Food portion size affects energy intake. In this study, young adult men and women were served four different portions of macaroni and cheese for lunch on different days, and were allowed to consume as much food as they liked [1]. The data demonstrate a linear relationship between portion size served and intake: increasing the amount of macaroni and cheese served increased the amount that was consumed.
Rolls BJ, Morris EL, Roe LS. Portion size of food affects energy intake in normal-weight and overweight men and women. Am J Clin Nutr 2002 Dec;76(6):1207-13.
27. Diet Energy Density, Independent of Fat Content, Influences Energy Intake Diet energy density, independent of fat content, influences energy intake
When food palatability is kept constant, energy density affects short-term energy intake, independent of fat content. In this study, 18 lean women were given free access to either low, medium, or high energy density meals for 2 days on three separate occasions [1]. The macronutrient content (percentage of calories from fat, protein, and carbohydrates) was the same for each diet and each diet had similar palatability ratings. The study participants ate a similar weight of food during each 2-day test period, although the available foods varied in energy density. Compared with the consumption of high-energy-dense foods, the consumption of low-energy-dense foods was associated with a 30% reduction in daily energy intake. Despite this difference in energy intake, subjects felt just as full when eating the low-energy-dense diet as when eating the high-energy-dense diet.
Bell EA, Castellanos VH, Pelkman CL, et al. Energy density of foods affects energy intake in normal-weight women. Am J Clin Nutr 1998;67:412-420.Diet energy density, independent of fat content, influences energy intake
When food palatability is kept constant, energy density affects short-term energy intake, independent of fat content. In this study, 18 lean women were given free access to either low, medium, or high energy density meals for 2 days on three separate occasions [1]. The macronutrient content (percentage of calories from fat, protein, and carbohydrates) was the same for each diet and each diet had similar palatability ratings. The study participants ate a similar weight of food during each 2-day test period, although the available foods varied in energy density. Compared with the consumption of high-energy-dense foods, the consumption of low-energy-dense foods was associated with a 30% reduction in daily energy intake. Despite this difference in energy intake, subjects felt just as full when eating the low-energy-dense diet as when eating the high-energy-dense diet.
Bell EA, Castellanos VH, Pelkman CL, et al. Energy density of foods affects energy intake in normal-weight women. Am J Clin Nutr 1998;67:412-420.
28. Effects of Fat and Water Content on Energy Density Effects of fat and water content on energy density
Water and fat content of food are important determinants of energy density. These graphs show the linear relationship between the fat and water content of over 100 commonly consumed foods and their energy density [1]. In general, foods that are high in fat content are high in energy density, whereas foods that are high in water content are low in energy density. Low-fat dry foods, such as pretzels and crackers, are high in energy density. Cheese and pretzels have the same energy density (3.8 kcal/g); although cheese obtains about a third of its calories from fat, it has a high water content, which adds weight but no calories.
Rolls BJ, Bell EA. Dietary approaches to the treatment of obesity. Med Clin North Am 2000;84:401-418.Effects of fat and water content on energy density
Water and fat content of food are important determinants of energy density. These graphs show the linear relationship between the fat and water content of over 100 commonly consumed foods and their energy density [1]. In general, foods that are high in fat content are high in energy density, whereas foods that are high in water content are low in energy density. Low-fat dry foods, such as pretzels and crackers, are high in energy density. Cheese and pretzels have the same energy density (3.8 kcal/g); although cheese obtains about a third of its calories from fat, it has a high water content, which adds weight but no calories.
Rolls BJ, Bell EA. Dietary approaches to the treatment of obesity. Med Clin North Am 2000;84:401-418.
29. Relationship Between Adiposity and Frequency of Eating in a Restaurant Relationship between adiposity and frequency of eating in a restaurant
Eating in restaurants increases the challenge of successful weight management. The combination of large portion sizes, high-energy-density foods, food variety, convivial company, and alcoholic beverages commonly associated with restaurant eating enhances energy intake. This graph shows that the frequency of eating out is positively associated with body fatness. Usual intakes and frequency of consuming food from seven different restaurant types (fried chicken, burger, pizza, Chinese, Mexican, fried fish, and other) were assessed by using a food frequency questionnaire in 73 men and women. The average frequency of eating in a restaurant was 7.5 times/month. The frequency of restaurant eating was directly correlated with higher fat and energy intakes, and lower fiber intake.
The following strategies can be used to help individuals eat out without overeating: 1) choose restaurants that offer healthier menu options or low-fat dishes; 2) limit fat intake by requesting less fat be used in food preparation, that butter not be served, and salad dressing on the side; 3) avoid all-you-can-eat buffets; 4) plan what will be ordered before arriving at the restaurant; 5) eat a low-calorie, low-energy-density snack before arriving at the restaurant to reduce hunger; 6) avoid large portions: request the order to be split or ask for a half order, order just a salad and an appetizer, leave food on the plate or ask for a doggie bag; 7) ask the server to remove tempting foods from the table when enough has been consumed.
McCrory MA, Fuss PJ, Hays NP, et al. Overeating in America: association between restaurant food consumption and body fatness in healthy adult men and women ages 19 to 80. Obes Res 1999;7:564-571.Relationship between adiposity and frequency of eating in a restaurant
Eating in restaurants increases the challenge of successful weight management. The combination of large portion sizes, high-energy-density foods, food variety, convivial company, and alcoholic beverages commonly associated with restaurant eating enhances energy intake. This graph shows that the frequency of eating out is positively associated with body fatness. Usual intakes and frequency of consuming food from seven different restaurant types (fried chicken, burger, pizza, Chinese, Mexican, fried fish, and other) were assessed by using a food frequency questionnaire in 73 men and women. The average frequency of eating in a restaurant was 7.5 times/month. The frequency of restaurant eating was directly correlated with higher fat and energy intakes, and lower fiber intake.
The following strategies can be used to help individuals eat out without overeating: 1) choose restaurants that offer healthier menu options or low-fat dishes; 2) limit fat intake by requesting less fat be used in food preparation, that butter not be served, and salad dressing on the side; 3) avoid all-you-can-eat buffets; 4) plan what will be ordered before arriving at the restaurant; 5) eat a low-calorie, low-energy-density snack before arriving at the restaurant to reduce hunger; 6) avoid large portions: request the order to be split or ask for a half order, order just a salad and an appetizer, leave food on the plate or ask for a doggie bag; 7) ask the server to remove tempting foods from the table when enough has been consumed.
McCrory MA, Fuss PJ, Hays NP, et al. Overeating in America: association between restaurant food consumption and body fatness in healthy adult men and women ages 19 to 80. Obes Res 1999;7:564-571.
30. Prevalence of Obesity by Hours of TV per Day: NHES Youth Aged 12-17 in 1967-70 and NLSY Youth Aged 10-15 in 1990 Patient message: Turn off the tube. Our lowest metabolic rate is sleeping. Our next lowest is watching T.V.Patient message: Turn off the tube. Our lowest metabolic rate is sleeping. Our next lowest is watching T.V.
31. There are too many. We cant treat obesity because we would be treating everyone with everything.
32. Expert Panel of NHLBI: Assessing Obesity - BMI, Waist Circumference, and Disease Risk Patient message: Fat in the belly is worse than fat elsewhere.Patient message: Fat in the belly is worse than fat elsewhere.
33. Expert Panel of NHLBI: Overall Risk of Obesity Evaluate the potential presence of other risk factors.
Some conditions associated with obesity put patients at high risk for subsequent mortality, and will require aggressive modification.
Other obesity associated conditions are less lethal, but still require treatment.
Among the risks to consider are: coronary heart disease, other atherosclerotic diseases, type 2 diabetes mellitus, sleep apnea, gynecological abnormalities, osteoarthritis, gallstones, stress incontinence, hypertension, cigarette smoking, hyperlipidemia, and family history of early coronary disease.
34. Expert Panel of NHLBI: Therapy Decision Therapy is Recommended:
BMI > 30
BMI 25 - 29.9, a dangerous waist circumference and 2 or more risk factors.
Individuals at lesser risk should be counseled about useful lifestyle changes if they are ready for a change.
35. So what can we do? There are all these diets and pills on the TV, but nothing seems to work very well. Is there anything that actually helps.
36. NHLBI Expert Panel: Goals of Therapy Reduce body weight and maintain a lower body weight for the long term.
An initial weight loss target of 10% of body weight, lost over six months is recommended and will be medically significant. The rate of weight loss should be 1 -2 pounds each week.
Evidence indicates that greater rates of weight loss do not achieve better long-term results.
After the first six months of weight loss therapy, the priority should be weight maintenance through combined changes in diet, physical activity, and behavior.
37. Obese Patients Have Unrealistic Weight Loss Goals Obese patients have unrealistic weight loss goals
Most obese patients have unrealistic weight loss goals. In patients seeking weight loss therapy, there is considerable disparity between weight loss expectations and weight loss that can be reasonably achieved. This table shows data from a study of obese women who were about to start a weight loss program [1]. On average, they reported their goal was to lose 32% of their weight. These women also reported that their dream was to lose 38% of their weight, they would be happy with a 31% weight loss, they would accept a 25% weight loss, but they would be disappointed with a 17% weight loss [1]. Therefore, an acceptable weight loss for most patients is 2 to 3 times more than that achieved with current behavioral and pharmacologic treatments. After 48 weeks of intensive diet and exercise therapy, subjects participating in this study lost an average of 16% of their initial weight, and end-of-treatment weights for 47% of patients were lower than that defined as disappointing. Patients who seek bariatric surgery also have unrealistically high weight loss expectations [2].
These studies illustrate the need to help patients accept more modest, but clinically important, weight loss outcomes. This can be done by redefining success as an improvement in health and quality of life, discussing limits to weight loss, congratulating patients on weight that has been lost, and empathizing with their disappointment if they do not reach their goal weight.
Foster GD, Wadden TA, Vogt RA, Brewer G. What is a reasonable weight loss? Patients expectations and evaluations of obesity treatment outcomes. J Consult Clin Psychol 1997;65:79-85.
Rabner JG, Greenstein RJ. Obesity surgery: expectations and reality. Int J Obes Relat Metab Disord 1991;15:841-855.Obese patients have unrealistic weight loss goals
Most obese patients have unrealistic weight loss goals. In patients seeking weight loss therapy, there is considerable disparity between weight loss expectations and weight loss that can be reasonably achieved. This table shows data from a study of obese women who were about to start a weight loss program [1]. On average, they reported their goal was to lose 32% of their weight. These women also reported that their dream was to lose 38% of their weight, they would be happy with a 31% weight loss, they would accept a 25% weight loss, but they would be disappointed with a 17% weight loss [1]. Therefore, an acceptable weight loss for most patients is 2 to 3 times more than that achieved with current behavioral and pharmacologic treatments. After 48 weeks of intensive diet and exercise therapy, subjects participating in this study lost an average of 16% of their initial weight, and end-of-treatment weights for 47% of patients were lower than that defined as disappointing. Patients who seek bariatric surgery also have unrealistically high weight loss expectations [2].
These studies illustrate the need to help patients accept more modest, but clinically important, weight loss outcomes. This can be done by redefining success as an improvement in health and quality of life, discussing limits to weight loss, congratulating patients on weight that has been lost, and empathizing with their disappointment if they do not reach their goal weight.
Foster GD, Wadden TA, Vogt RA, Brewer G. What is a reasonable weight loss? Patients expectations and evaluations of obesity treatment outcomes. J Consult Clin Psychol 1997;65:79-85.
Rabner JG, Greenstein RJ. Obesity surgery: expectations and reality. Int J Obes Relat Metab Disord 1991;15:841-855.
38. NHLBI Expert Panel: Changes in Lifestyle or Priorities Food
Diets chosen should be long-term
Reduced 500 to 1000 from baseline in calories
Targeting 30% or less of calories as fat
Individualized.
Activity
Activity is most useful in maintaining weight loss
Goal of 30 minutes of moderate activity every day
Increase everyday activity by taking the stairs, etc.
39. Providing Prepackaged Meals Enhances Weight Loss Providing prepackaged meals enhances weight loss
The use of prepackaged meal replacements provides portion-controlled servings, which can facilitate weight loss by reducing the consumption of inappropriate foods, thereby increasing the reliability of estimated energy intake, decreasing food options, and increasing compliance with a treatment program. This randomized, controlled trial evaluated the effect of providing prepackaged meals in conjunction with behavior therapy on weight loss [1]. The data shown in this figure are from subjects who were 1) instructed to do whatever they wished to lose weight but did not receive any intervention (control group); 2) given standard behavior therapy and instructions for a low-calorie diet (10001500 kcal/d; behavior therapy/self-selected diet group); and 3) given standard behavior therapy and instructions for a low-calorie diet (10001500 kcal/d), which included the provision of prepackaged meals for breakfast and dinner 5 d/wk (behavior therapy/food provision group). At all evaluation time points, subjects provided with appropriate foods lost more weight than those prescribed a self-selected diet. Subjects provided with food lost approximately one third more weight at 6 months, 100% more weight at 12 months, and 40% more weight at 18 months than those assigned a self-selected diet. Food provision also enhanced attendance and completion of food records.
In a follow-up study, these investigators found that the provision of a structured meal plan, rather than the provision of foods per se, also can cause successful weight loss [2]. Subjects who were provided a meal plan that told them precisely what foods to purchase lost more weight than those who were prescribed the same number of calories but consumed a self-selected diet. Providing foods, in addition to the meal plan, did not produce greater weight loss than the meal plan alone.
Obese patients with concomitant obesity-related medical complications also can benefit from meal replacement therapy. In a recent randomized controlled trial conducted in persons with hypertension, dyslipidemia, or type 2 diabetes, those who received prepackaged meals lost three times as much weight at the end of 1 year than those randomized to a standard exchange system diet (6 kg vs 2 kg in the hypertension/dyslipidemia group, P<0.001; 3 kg vs 1 kg in the diabetes group, P<0.001) [3].
Jeffery RW, Wing RR, Thorson C, et al. Strengthening behavioral interventions for weight loss: A randomized trial of food provision and monetary incentives. J Consul Clin Psychol 1993;61:1038-1045.
Wing RR, Jeffery RW, Burton LR, et al. Food provisions vs structured meal plans in the behavioral treatment of obesity. Int J Obes Relat Metab Disord 1996;20:56-62.
Metz JA, Stern JS, Kris-Etherton P, et al. A randomized trial of improved weight loss with a prepared meal plan in overweight and obese patients. Arch Intern Med 2000;160:2150-2158.Providing prepackaged meals enhances weight loss
The use of prepackaged meal replacements provides portion-controlled servings, which can facilitate weight loss by reducing the consumption of inappropriate foods, thereby increasing the reliability of estimated energy intake, decreasing food options, and increasing compliance with a treatment program. This randomized, controlled trial evaluated the effect of providing prepackaged meals in conjunction with behavior therapy on weight loss [1]. The data shown in this figure are from subjects who were 1) instructed to do whatever they wished to lose weight but did not receive any intervention (control group); 2) given standard behavior therapy and instructions for a low-calorie diet (10001500 kcal/d; behavior therapy/self-selected diet group); and 3) given standard behavior therapy and instructions for a low-calorie diet (10001500 kcal/d), which included the provision of prepackaged meals for breakfast and dinner 5 d/wk (behavior therapy/food provision group). At all evaluation time points, subjects provided with appropriate foods lost more weight than those prescribed a self-selected diet. Subjects provided with food lost approximately one third more weight at 6 months, 100% more weight at 12 months, and 40% more weight at 18 months than those assigned a self-selected diet. Food provision also enhanced attendance and completion of food records.
In a follow-up study, these investigators found that the provision of a structured meal plan, rather than the provision of foods per se, also can cause successful weight loss [2]. Subjects who were provided a meal plan that told them precisely what foods to purchase lost more weight than those who were prescribed the same number of calories but consumed a self-selected diet. Providing foods, in addition to the meal plan, did not produce greater weight loss than the meal plan alone.
Obese patients with concomitant obesity-related medical complications also can benefit from meal replacement therapy. In a recent randomized controlled trial conducted in persons with hypertension, dyslipidemia, or type 2 diabetes, those who received prepackaged meals lost three times as much weight at the end of 1 year than those randomized to a standard exchange system diet (6 kg vs 2 kg in the hypertension/dyslipidemia group, P<0.001; 3 kg vs 1 kg in the diabetes group, P<0.001) [3].
Jeffery RW, Wing RR, Thorson C, et al. Strengthening behavioral interventions for weight loss: A randomized trial of food provision and monetary incentives. J Consul Clin Psychol 1993;61:1038-1045.
Wing RR, Jeffery RW, Burton LR, et al. Food provisions vs structured meal plans in the behavioral treatment of obesity. Int J Obes Relat Metab Disord 1996;20:56-62.
Metz JA, Stern JS, Kris-Etherton P, et al. A randomized trial of improved weight loss with a prepared meal plan in overweight and obese patients. Arch Intern Med 2000;160:2150-2158.
40. I dont think I need to change what I am eating.
I am going to work out and lose it that way.
41. Physical Activity Alone Results in Minimal Weight Loss Physical activity alone results in minimal weight loss
Exercise alone, without concomitant dietary therapy, produces minimal weight loss. The results from most studies have demonstrated that participating in regular endurance exercise activities (eg, brisk walking for 4560 min, 4 times weekly) for up to a year without an energy-restricted diet, usually results in minimal weight loss (an average 2-kg decrease in body weight compared with a control group) [1-8]. Moreover, it is not known whether weight loss was due to exercise alone or whether the participants also altered their dietary intake because they were enrolled in an exercise program. In addition, these data may not represent the effect of exercise in obese persons because most subjects enrolled in these studies were slightly overweight men. Vigorous exercise training causes much greater losses in body weight when energy intake is held constant [9].
Wing RR. Physical activity in the treatment of the adulthood overweight and obesity: current evidence and research issues. Med Sci Sports Exerc 1999;31(suppl)S547-S552.
Anderssen S, Holme I, Urdal P, Hjermann I. Diet and exercise intervention have favourable effects on blood pressure in mild hypertensives: the Oslo Diet and Exercise Study (ODES). Blood Press 1995;4:343-349.
Hammer RL, Barrier CA, Roundy ES, et al. Calorie-restricted low-fat diet and exercise in obese women. Am J Clin Nutr 1989;49:77-85.
Rnnemaa T, Marniemi J, Puukka P, Kuusi T. Effects of long-term physical exercise on serum lipids, lipoproteins, and lipid metabolizing enzymes in type 2 (non-insulin-dependent) diabetic patients. Diabetes Res 1988;7:79-84.
Stefanick ML, Mackey S, Sheehan M, et al. Effects of the NCEP Step 2 diet and exercise on lipoprotein in postmenopausal women and men with low high density lipoprotein (HDL)-cholesterol and high low density lipoprotein (LDL)-cholesterol. N Engl J Med 1998;329:12-20.
Verity LS, Ismail AH. Effects of exercise on cardiovascular disease risk in women with NIDDM. Diabetes Res Clin Pract 1989;6:27-35.
Wood PD, Haskell WL, Blair SN, et al. Increased exercise level and plasma lipoprotein concentrations: a one-year, randomized, controlled study in sedentary, middle-aged men. Metabolism 1983;32:31-37.
Wood PD, Stefanick ML, Dreon DM, et al. Changes in plasma lipids and lipoproteins in overweight men during weight loss through dieting as compared with exercise. N Engl J Med 1988;319:1173-1179.
Bouchard C, Tremblay AJ, Nadeau A, et al. Long-term exercise training with constant energy intake: effect on body composition and selected metabolic variables. Int J Obes 1990;14:57-73.
Physical activity alone results in minimal weight loss
Exercise alone, without concomitant dietary therapy, produces minimal weight loss. The results from most studies have demonstrated that participating in regular endurance exercise activities (eg, brisk walking for 4560 min, 4 times weekly) for up to a year without an energy-restricted diet, usually results in minimal weight loss (an average 2-kg decrease in body weight compared with a control group) [1-8]. Moreover, it is not known whether weight loss was due to exercise alone or whether the participants also altered their dietary intake because they were enrolled in an exercise program. In addition, these data may not represent the effect of exercise in obese persons because most subjects enrolled in these studies were slightly overweight men. Vigorous exercise training causes much greater losses in body weight when energy intake is held constant [9].
Wing RR. Physical activity in the treatment of the adulthood overweight and obesity: current evidence and research issues. Med Sci Sports Exerc 1999;31(suppl)S547-S552.
Anderssen S, Holme I, Urdal P, Hjermann I. Diet and exercise intervention have favourable effects on blood pressure in mild hypertensives: the Oslo Diet and Exercise Study (ODES). Blood Press 1995;4:343-349.
Hammer RL, Barrier CA, Roundy ES, et al. Calorie-restricted low-fat diet and exercise in obese women. Am J Clin Nutr 1989;49:77-85.
Rnnemaa T, Marniemi J, Puukka P, Kuusi T. Effects of long-term physical exercise on serum lipids, lipoproteins, and lipid metabolizing enzymes in type 2 (non-insulin-dependent) diabetic patients. Diabetes Res 1988;7:79-84.
Stefanick ML, Mackey S, Sheehan M, et al. Effects of the NCEP Step 2 diet and exercise on lipoprotein in postmenopausal women and men with low high density lipoprotein (HDL)-cholesterol and high low density lipoprotein (LDL)-cholesterol. N Engl J Med 1998;329:12-20.
Verity LS, Ismail AH. Effects of exercise on cardiovascular disease risk in women with NIDDM. Diabetes Res Clin Pract 1989;6:27-35.
Wood PD, Haskell WL, Blair SN, et al. Increased exercise level and plasma lipoprotein concentrations: a one-year, randomized, controlled study in sedentary, middle-aged men. Metabolism 1983;32:31-37.
Wood PD, Stefanick ML, Dreon DM, et al. Changes in plasma lipids and lipoproteins in overweight men during weight loss through dieting as compared with exercise. N Engl J Med 1988;319:1173-1179.
Bouchard C, Tremblay AJ, Nadeau A, et al. Long-term exercise training with constant energy intake: effect on body composition and selected metabolic variables. Int J Obes 1990;14:57-73.
42. Relationship Between Physical Activity and Maintenance of Weight Loss Relationship between physical activity and maintenance of weight loss
Although increasing physical activity may not improve short-term weight loss, physical activity may be very important for long-term weight management. However, most long-term (>10 months) prospective randomized controlled trials have not demonstrated a statistically significant beneficial effect of exercise on body weight, when data were analyzed on an intention-to-treat basis [1,2]. The failure to detect a beneficial effect of exercise on body weight may be related to poor compliance with an exercise program. However, large cross-sectional case studies and retrospective analyses of prospective trials found that successful long-term (>1 y) weight loss was associated with participation in regular exercise [3-6]. This figure shows data from one study that found 90% of formerly obese women who achieved and maintained average weight exercised regularly, compared with 34% of obese women who regained weight after successful weight loss (P<0.001) [3].
Wadden TA, Vogt RA, Anderson RE, et al. Exercise in the treatment of obesity: effects of four interventions on body composition, resting energy expenditure, appetite and mood. J Consult Clin Psychol 1997;65:269-277.
Jeffery RW, Wing RR, Thorson C, Burton LR. Use of personal trainers and financial incentives to increase exercise in a behavioral weight loss program. J Consult Clin Psychol 1998;66:777-783.
Kayman S, Bruvold W, Stern JS. Maintenance and relapse after weight loss in women: behavioral aspects. Am J Clin Nutr 1990;52:800-807.
Marston AR, Criss J. Maintenance of successful weight loss: incidence and prediction. Int J Obes 1984;8:435-439.
Jeffery RW, Bjornson-Benson WM, Rosenthal BS, et al. Correlates of weight loss and its maintenance over two years of follow-up among middle-aged men. Prev Med 1984;13:155-168.
Hartman WM, Straud M, Sweet DM, Saxton J. Long-term maintenance of weight loss following supplemented fasting. Int J Eat Disord 1993;87-93.Relationship between physical activity and maintenance of weight loss
Although increasing physical activity may not improve short-term weight loss, physical activity may be very important for long-term weight management. However, most long-term (>10 months) prospective randomized controlled trials have not demonstrated a statistically significant beneficial effect of exercise on body weight, when data were analyzed on an intention-to-treat basis [1,2]. The failure to detect a beneficial effect of exercise on body weight may be related to poor compliance with an exercise program. However, large cross-sectional case studies and retrospective analyses of prospective trials found that successful long-term (>1 y) weight loss was associated with participation in regular exercise [3-6]. This figure shows data from one study that found 90% of formerly obese women who achieved and maintained average weight exercised regularly, compared with 34% of obese women who regained weight after successful weight loss (P<0.001) [3].
Wadden TA, Vogt RA, Anderson RE, et al. Exercise in the treatment of obesity: effects of four interventions on body composition, resting energy expenditure, appetite and mood. J Consult Clin Psychol 1997;65:269-277.
Jeffery RW, Wing RR, Thorson C, Burton LR. Use of personal trainers and financial incentives to increase exercise in a behavioral weight loss program. J Consult Clin Psychol 1998;66:777-783.
Kayman S, Bruvold W, Stern JS. Maintenance and relapse after weight loss in women: behavioral aspects. Am J Clin Nutr 1990;52:800-807.
Marston AR, Criss J. Maintenance of successful weight loss: incidence and prediction. Int J Obes 1984;8:435-439.
Jeffery RW, Bjornson-Benson WM, Rosenthal BS, et al. Correlates of weight loss and its maintenance over two years of follow-up among middle-aged men. Prev Med 1984;13:155-168.
Hartman WM, Straud M, Sweet DM, Saxton J. Long-term maintenance of weight loss following supplemented fasting. Int J Eat Disord 1993;87-93.
43. Considerable Physical Activity is Necessary for Weight Loss Maintenance Considerable physical activity is necessary for weight loss maintenance
The amount of physical activity required to maintain weight loss appears to be much greater than that recommended by the American College of Sports Medicine and the Centers for Disease Control and Prevention for good health, (30 minutes of moderate-intensity exercise on most days of the week) [1]. Data from most studies suggest that successful long-term weight maintenance is associated with regular activity that expends approximately 2500 kcal/wk, which is equivalent to moderate activity, such as brisk walking, for approximately 6075 minutes per day, or vigorous activity, such as aerobics, cycling or jogging, for 30 minutes per day [2-5]. In this figure, data are presented that show a dose-response relationship between amount of exercise per week and change in body weight [3]. At 18 months, weight loss in participants who spent at least 200 minutes per week in physical activity (-13.1 kg) was greater than those exercising for at least 150 minutes per week (-8.5 kg) and those exercising less than 150 minutes per week (-3.5 kg). However, these data represent a retrospective analysis of subjects who chose to exercise at different levels of activity and does not represent those who were randomized to those levels of activity.
Pate RR, Pratt M, Blair SN, et al. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402-407.
Schoeller DA, Shay K, Kushner RF. How much physical activity is needed to minimize weight gain in previously obese women? Am J Clin Nutr 1997;66:551-556.
Jakicic JM, Winters C, Lang W, Wing RR. Effects of intermittent exercise and use of home exercise equipment on adherence, weight loss, and fitness in overweight women. JAMA 1999;282:1554-1560.
Jeffery RW, Wing RR, Thorson C, Burton LR. Use of personal trainers and financial incentives to increase exercise in a behavioral weight loss program. J Consult Clin Psychol 1998;66:777-783.
Wing RR, Tate DF. Lifestyle changes to reduce obesity. Curr Opin Endocrinol Diabetes 2000;7:240-246.Considerable physical activity is necessary for weight loss maintenance
The amount of physical activity required to maintain weight loss appears to be much greater than that recommended by the American College of Sports Medicine and the Centers for Disease Control and Prevention for good health, (30 minutes of moderate-intensity exercise on most days of the week) [1]. Data from most studies suggest that successful long-term weight maintenance is associated with regular activity that expends approximately 2500 kcal/wk, which is equivalent to moderate activity, such as brisk walking, for approximately 6075 minutes per day, or vigorous activity, such as aerobics, cycling or jogging, for 30 minutes per day [2-5]. In this figure, data are presented that show a dose-response relationship between amount of exercise per week and change in body weight [3]. At 18 months, weight loss in participants who spent at least 200 minutes per week in physical activity (-13.1 kg) was greater than those exercising for at least 150 minutes per week (-8.5 kg) and those exercising less than 150 minutes per week (-3.5 kg). However, these data represent a retrospective analysis of subjects who chose to exercise at different levels of activity and does not represent those who were randomized to those levels of activity.
Pate RR, Pratt M, Blair SN, et al. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402-407.
Schoeller DA, Shay K, Kushner RF. How much physical activity is needed to minimize weight gain in previously obese women? Am J Clin Nutr 1997;66:551-556.
Jakicic JM, Winters C, Lang W, Wing RR. Effects of intermittent exercise and use of home exercise equipment on adherence, weight loss, and fitness in overweight women. JAMA 1999;282:1554-1560.
Jeffery RW, Wing RR, Thorson C, Burton LR. Use of personal trainers and financial incentives to increase exercise in a behavioral weight loss program. J Consult Clin Psychol 1998;66:777-783.
Wing RR, Tate DF. Lifestyle changes to reduce obesity. Curr Opin Endocrinol Diabetes 2000;7:240-246.
44. Effect of Decreasing Sedentary Activities vs Increasing Physical Activities on Body Weight in Children 6-12 Years Old Effect of decreasing sedentary activities vs increasing physical activities on body weight in children 612 years old
A strategy of reducing childrens sedentary behavior can be more effective than a strategy of promoting physical activity. Epstein and colleagues [1] studied overweight children who underwent a 4-month program in which they learned the Stoplight diet and behavior modification techniques. One group of children received reinforcement for increased physical activity. Another group received reinforcement for reducing the hours spent watching television or other sedentary behavior but not for replacing that time with physical activity. In the group that decreased sedentary behavior, percent overweight declined by an average of 20% compared with less than 15% in the physical activity group. The superior effects were maintained at the 12-month follow-up.
The American Academy of Pediatrics recommends limitation of television viewing to 1 or 2 hours daily [2]. Healthcare providers should advise overweight children and adolescents and their families to stay within this recommended limit.
Epstein LH, Valoski AM, Vara LS, et al. Effects of decreasing sedentary behavior and increasing activity on weight change in obese children. Health Psychology 1995;14:109-115.
American Academy of Pediatrics Committee on Communication. Children, adolescents, and television. Pediatrics 1995;96:786-787.
Barlow SE, Dietz WH. Obesity evaluation and treatment: expert committee recommendations. Pediatrics 1998;102:e29. Available at: www.pediatrics.org/cgi/content/full/102/3/e29.
Effect of decreasing sedentary activities vs increasing physical activities on body weight in children 612 years old
A strategy of reducing childrens sedentary behavior can be more effective than a strategy of promoting physical activity. Epstein and colleagues [1] studied overweight children who underwent a 4-month program in which they learned the Stoplight diet and behavior modification techniques. One group of children received reinforcement for increased physical activity. Another group received reinforcement for reducing the hours spent watching television or other sedentary behavior but not for replacing that time with physical activity. In the group that decreased sedentary behavior, percent overweight declined by an average of 20% compared with less than 15% in the physical activity group. The superior effects were maintained at the 12-month follow-up.
The American Academy of Pediatrics recommends limitation of television viewing to 1 or 2 hours daily [2]. Healthcare providers should advise overweight children and adolescents and their families to stay within this recommended limit.
Epstein LH, Valoski AM, Vara LS, et al. Effects of decreasing sedentary behavior and increasing activity on weight change in obese children. Health Psychology 1995;14:109-115.
American Academy of Pediatrics Committee on Communication. Children, adolescents, and television. Pediatrics 1995;96:786-787.
Barlow SE, Dietz WH. Obesity evaluation and treatment: expert committee recommendations. Pediatrics 1998;102:e29. Available at: www.pediatrics.org/cgi/content/full/102/3/e29.
45. This is so hard. Is there any good news?
46. Diabetes Prevention Program (DPP) Hypothesis: Can diabetes be delayed or prevented by addressing risk factors: impaired glucose tolerance, overweight and sedentary life - using lifestyle changes or metformin?
3234 pts of mean age 51, BMI 34, 68% women, 45% minorities and impaired glucose tolerance were randomized to 3 groups at 27 US centers:
Usual care (control)
Metformin 850 mg BID
Lifestyle intervention
Goal of 7% weight loss by Food Pyramid, NCEP 1 diet
Goal of 150 min/wk moderate activity (brisk walking)
47. Diabetes Development in Diabetes Prevention Program
48. Obesity treatment and behavior change are too hard. I dont have time to do this in my clinic.
49. Practical Behavior Change Physicians make a difference
Repetition and follow-up are most useful
Likely better to do with 2-5 minutes repeatedly than with an hour at once
Education can be done in pieces
Let them know that you know its hard and that the environment is against them
Encourage patients to find their own goals (motivational interviewing techniques) but encourage specificity - go beyond watch what I eat
50. Five Steps to Facilitate Behavior Change Five steps to facilitate behavior change
Five steps that clinical practitioners can take to facilitate behavior changes in their patients are:
1. Identify the specific behavior change that is desired.
2. Review when, where, and how the new behaviors will be performed.
3. Instruct the patient to keep a record of the behavior change.
4. Review the patients progress at each treatment visit.
5. Congratulate the patient on successes that have been achieved, but do not criticize failures. Criticism may cause embarrassment and a loss of self-esteem, which may make it uncomfortable for the patient to continue treatment.
Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am 2000;84:441-461.Five steps to facilitate behavior change
Five steps that clinical practitioners can take to facilitate behavior changes in their patients are:
1. Identify the specific behavior change that is desired.
2. Review when, where, and how the new behaviors will be performed.
3. Instruct the patient to keep a record of the behavior change.
4. Review the patients progress at each treatment visit.
5. Congratulate the patient on successes that have been achieved, but do not criticize failures. Criticism may cause embarrassment and a loss of self-esteem, which may make it uncomfortable for the patient to continue treatment.
Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am 2000;84:441-461.
51. Cardinal Behaviors of Successful Long-term Weight Management National Weight Control Registry Data Self-monitoring:
Diet: record food intake daily, limit certain foods or food quantity
Weight: check body weight >1 x/wk
Low-calorie, low-fat diet:
Total energy intake: 1300-1400 kcal/d
Energy intake from fat: 20%-25%
Eat breakfast daily
Regular physical activity: 2500-3000 kcal/wk (eg, walk 4 miles/d) Cardinal behaviors of successful long-term weight management
Data obtained from the National Weight Control Registry (NWCR) have identified specific behaviors that are associated with successful long-term weight loss [1-3]. Participants enrolled in the registry must have maintained a weight loss of ?13.6 kg (?30 lb) for at least 1 year; on average, subjects have maintained a 32 kg (70 lb) weight loss for 6 years. The major behaviors reported by approximately 3000 NWCR participants were: 1) self-monitoring of food intake and body weight; 2) consuming a low-calorie (13001400 kcal/d) and low-fat diet (20%25% of daily energy intake from fat), 3) eating breakfast every day, and 4) performing regular physical activity that expends 2500 to 3000 kcal per week (eg, walking 4 miles per day).
Klem ML, Wing RR, McGuire MT, et al. A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am J Clin Nutr 1997;66:239-246.
McGuire MT, Wing RR, Klem ML, et al. Long-term maintenance of weight loss: do people who lose weight through various weight loss methods use different behaviors to maintain their weight? Int J Obes Relat Metab Disord 1998;22:572-577.
Wyatt HR, Grunwald GK, Mosca CL et al. Long-term weight loss and breakfast in the National Weight Control Registry. Obes Res 2002;10:78-82.Cardinal behaviors of successful long-term weight management
Data obtained from the National Weight Control Registry (NWCR) have identified specific behaviors that are associated with successful long-term weight loss [1-3]. Participants enrolled in the registry must have maintained a weight loss of ?13.6 kg (?30 lb) for at least 1 year; on average, subjects have maintained a 32 kg (70 lb) weight loss for 6 years. The major behaviors reported by approximately 3000 NWCR participants were: 1) self-monitoring of food intake and body weight; 2) consuming a low-calorie (13001400 kcal/d) and low-fat diet (20%25% of daily energy intake from fat), 3) eating breakfast every day, and 4) performing regular physical activity that expends 2500 to 3000 kcal per week (eg, walking 4 miles per day).
Klem ML, Wing RR, McGuire MT, et al. A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am J Clin Nutr 1997;66:239-246.
McGuire MT, Wing RR, Klem ML, et al. Long-term maintenance of weight loss: do people who lose weight through various weight loss methods use different behaviors to maintain their weight? Int J Obes Relat Metab Disord 1998;22:572-577.
Wyatt HR, Grunwald GK, Mosca CL et al. Long-term weight loss and breakfast in the National Weight Control Registry. Obes Res 2002;10:78-82.
52. Long-term Weight Loss is Improved with Long-term Maintenance Therapy Long-term weight loss is improved with long-term maintenance therapy
Maintenance therapy is important for long-term weight management success after initial weight loss is achieved by diet and behavior therapy. In this study, Perri and colleagues [1] randomized obese subjects who lost weight after 5 months of diet and behavior modification therapy to no maintenance or a maintenance program that involved biweekly contact. At 1 year after initial weight loss was achieved, participants who received maintenance therapy maintained long-term weight loss, whereas those who did not receive maintenance therapy regained half of their lost weight.
Perri MG, McAllister DA, Gange JJ, et al. Effects of four maintenance programs on the long-term management of obesity. J Consult Clin Psychol 1988;56:529-534.Long-term weight loss is improved with long-term maintenance therapy
Maintenance therapy is important for long-term weight management success after initial weight loss is achieved by diet and behavior therapy. In this study, Perri and colleagues [1] randomized obese subjects who lost weight after 5 months of diet and behavior modification therapy to no maintenance or a maintenance program that involved biweekly contact. At 1 year after initial weight loss was achieved, participants who received maintenance therapy maintained long-term weight loss, whereas those who did not receive maintenance therapy regained half of their lost weight.
Perri MG, McAllister DA, Gange JJ, et al. Effects of four maintenance programs on the long-term management of obesity. J Consult Clin Psychol 1988;56:529-534.
53. Assessing Weight Loss Readiness Motivation:
Stress level:
Psychiatric issues:
Time availability: Assessing weight loss readiness
Patient motivation, commitment, and compliance are critical for weight loss success. Therefore, knowledge of the patients readiness to lose weight will help in developing an appropriate treatment strategy. Good candidates for treatment are patients who decide they want to lose weight for appropriate reasons, are not currently experiencing major life stressors, do not have psychiatric or medical illnesses that prevent effective weight loss, and are willing to devote the time needed to make lifestyle changes. In addition, the patients work, social, and family environment should be considered in deciding if it is a good time to implement weight loss therapy. If the patient is considered to be ready to lose weight, weight loss therapy should be initiated. If the patient is not ready to lose weight, the immediate goal is to prevent further weight gain and explore barriers to weight reduction.
Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am 2000; 84:441-461.
NHLBI Obesity Education Initiative and North American Association for the Study of Obesity. The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NIH publication number 00-4084, October 2000.Assessing weight loss readiness
Patient motivation, commitment, and compliance are critical for weight loss success. Therefore, knowledge of the patients readiness to lose weight will help in developing an appropriate treatment strategy. Good candidates for treatment are patients who decide they want to lose weight for appropriate reasons, are not currently experiencing major life stressors, do not have psychiatric or medical illnesses that prevent effective weight loss, and are willing to devote the time needed to make lifestyle changes. In addition, the patients work, social, and family environment should be considered in deciding if it is a good time to implement weight loss therapy. If the patient is considered to be ready to lose weight, weight loss therapy should be initiated. If the patient is not ready to lose weight, the immediate goal is to prevent further weight gain and explore barriers to weight reduction.
Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am 2000; 84:441-461.
NHLBI Obesity Education Initiative and North American Association for the Study of Obesity. The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NIH publication number 00-4084, October 2000.
54. Prevention Breastfeeding when possible
Plotting BMI at each visit
Anticipatory guidance: 5-2-1-0
5 a day fruits and vegetables
Less than 2 hr/day of screen time
At least 1 hour of moderate activity each day
No sweet drinks
55. Appropriate Office Environment for Obese Patients Waiting room chairs without arms
Step stools next to examination tables
Large gowns and blood pressure cuffs
Scale that can weigh extremely obese patients, located in a private area
Appropriate obesity educational materials, handouts, and treatment protocols
Empathetic, respectful, and supportive office staff Appropriate office environment for obese patients
A supportive office environment is important in managing patients who are obese. This is true for physicians who treat obesity as well as those who provide general or subspecialty medical care. A proper office environment makes obese patients more comfortable, reduces embarrassment, and demonstrates understanding and sensitivity. Basic suggestions for establishing an appropriate office setting for obese patients are listed on this slide.Appropriate office environment for obese patients
A supportive office environment is important in managing patients who are obese. This is true for physicians who treat obesity as well as those who provide general or subspecialty medical care. A proper office environment makes obese patients more comfortable, reduces embarrassment, and demonstrates understanding and sensitivity. Basic suggestions for establishing an appropriate office setting for obese patients are listed on this slide.
56. Isnt there some popular diet I can follow? One that makes it easy.
57. Popular Diets Succeed short term because restriction in food choice reduces calories
Fail long term because restriction of food choices becomes unacceptable
Promote a cycle of euphoria and despair that discourages belief in the possibility of success
58. What about surgery?
59. Role of Surgery Evidence for long term effectiveness
Has serious dangers
Is approved by most payers
New questions about cost and who should be doing the surgeries
60. Common bariatric operations
61. Who qualifies for surgery? BMI greater than 40
BMI greater than 35 with obesity co-morbidity
Attendance in a plausible structured program for some period of time, without sustained and significant degree of weight loss
Not impaired psychiatrically?
BMI greater than 60?
62. Recommendations for bariatric surgery in children Limit to experienced bariatric surgeons.
Ongoing availability of multidisciplinary team.
Limited to skeletally mature (F13, M15) children.
Pre-operative management by multidisciplinary team for = 6 months
BMI = 40 with serious co-morbidities
BMI = 50 with less serious co-morbidities
Patient assent
Avoid pregnancy for one year
63. I cant lose weight. What am I going to do?
64. When the Patient Cant Lose Weight In some patients, weight loss is not achievable.
The goal for these patients should be prevention of further weight gain which would exacerbate disease
Prevention of gain can be a success in some of these individuals
Some people will benefit from weight management programs primarily by prevention of gain, rather than by weight loss
65. Why dont I just take a pill?
66. Role of Drugs An aid to doing what needs to be done
Not a program by themselves
Not infrequently ineffective
67. Mechanisms of Action: Sibutramine and Active Metabolites Block Serotonin and Norepinephrine Reuptake
68. Initial Responders to Sibutramine Can Maintain Long-term Weight Loss Initial responders to sibutramine can maintain long-term weight loss
The ability of sibutramine to maintain long-term weight loss in obese subjects who respond to short-term sibutramine therapy was evaluated in a randomized, controlled trial (STORM; Sibutramine Trial of Obesity Reduction and Maintenance) [1]. During the first 6 months (weight loss phase), all subjects received sibutramine (10 mg/d) and an individualized 600 kcal/d deficit diet program. Patients achieving at least a 5% weight loss, without regain during months 46, were then randomly assigned to treatment with either sibutramine (increased to 15 or 20 mg/d) or placebo for an additional 18 months. Sibutramine-treated subjects maintained their weight for the next year with a slight regain during the last 6 months (months 1824) of the study. In contrast, subjects randomized to placebo experienced an immediate and steady increase in body weight. Of the 204 sibutramine-treated patients who completed the trial, 89 (43%) maintained 80% or more of their original 6-month weight loss compared with 9 (16%) of the 57 patients in the placebo group; P<0.001. Of those who continued sibutramine therapy during the maintenance phase, 69% maintained at least a 5% weight loss, 46% maintained at least a 10% weight loss, and 27% maintained their full weight loss.
James WPT, Astrup A, Finer N, et al, for the STORM Study Group. Effect of sibutramine on weight maintenance after weight loss: a randomised trial. Lancet 2000;356:2119-2125.Initial responders to sibutramine can maintain long-term weight loss
The ability of sibutramine to maintain long-term weight loss in obese subjects who respond to short-term sibutramine therapy was evaluated in a randomized, controlled trial (STORM; Sibutramine Trial of Obesity Reduction and Maintenance) [1]. During the first 6 months (weight loss phase), all subjects received sibutramine (10 mg/d) and an individualized 600 kcal/d deficit diet program. Patients achieving at least a 5% weight loss, without regain during months 46, were then randomly assigned to treatment with either sibutramine (increased to 15 or 20 mg/d) or placebo for an additional 18 months. Sibutramine-treated subjects maintained their weight for the next year with a slight regain during the last 6 months (months 1824) of the study. In contrast, subjects randomized to placebo experienced an immediate and steady increase in body weight. Of the 204 sibutramine-treated patients who completed the trial, 89 (43%) maintained 80% or more of their original 6-month weight loss compared with 9 (16%) of the 57 patients in the placebo group; P<0.001. Of those who continued sibutramine therapy during the maintenance phase, 69% maintained at least a 5% weight loss, 46% maintained at least a 10% weight loss, and 27% maintained their full weight loss.
James WPT, Astrup A, Finer N, et al, for the STORM Study Group. Effect of sibutramine on weight maintenance after weight loss: a randomised trial. Lancet 2000;356:2119-2125.
69. Additive Effects of Behavior and Diet Therapy with Pharmacotherapy for Obesity Additive effects of behavior and diet therapy with pharmacotherapy for obesity
The use of pharmacotherapy alone is not as effective as pharmacotherapy given in conjunction with a comprehensive weight management program. The effect of adding behavior modification therapy and a portion-controlled diet with meal replacements to the pharmacologic treatment of obesity were compared in a 1-year study of 53 obese women randomized to 3 treatment groups: (1) medication alone (sibutramine 1015 mg daily), (2) medication plus behavior modification therapy, or (3) medication plus behavior modification plus a 1000 kcal/d portion-controlled diet that consisted of 4 servings daily of a nutritional supplement and an evening meal of a frozen food entre, a green salad, and a serving of fruit (combined treatment). All groups were prescribed a low-calorie diet and regular exercise regimen. Maximum weight loss was achieved by 6 months in all groups, and was significantly different between groups. At 12 months, subjects in the medication-alone group lost significantly less weight (4.1% of initial body weight) than the medication plus lifestyle group (10.8%) or the combined treatment group (16.5%); P<0.05 for both comparisons. In addition, after 1 year, more subjects in the two groups that involved lifestyle modification lost =5% or =10% of their initial body weight compared with subjects treated with medication alone (P<0.05 for both comparisons). These results suggest that drug treatment for obesity should only be provided in conjunction with other standard weight management approaches; drug treatment alone exposes patients to the full risks and costs of treatment without the full benefits.
Wadden TA, Berkowitz RI, Sarwer DB, et al. Benefits of lifestyle modification in the pharmacologic treatment of obesity. A randomized trial. Arch Intern Med 2001;161:218-227.Additive effects of behavior and diet therapy with pharmacotherapy for obesity
The use of pharmacotherapy alone is not as effective as pharmacotherapy given in conjunction with a comprehensive weight management program. The effect of adding behavior modification therapy and a portion-controlled diet with meal replacements to the pharmacologic treatment of obesity were compared in a 1-year study of 53 obese women randomized to 3 treatment groups: (1) medication alone (sibutramine 1015 mg daily), (2) medication plus behavior modification therapy, or (3) medication plus behavior modification plus a 1000 kcal/d portion-controlled diet that consisted of 4 servings daily of a nutritional supplement and an evening meal of a frozen food entre, a green salad, and a serving of fruit (combined treatment). All groups were prescribed a low-calorie diet and regular exercise regimen. Maximum weight loss was achieved by 6 months in all groups, and was significantly different between groups. At 12 months, subjects in the medication-alone group lost significantly less weight (4.1% of initial body weight) than the medication plus lifestyle group (10.8%) or the combined treatment group (16.5%); P<0.05 for both comparisons. In addition, after 1 year, more subjects in the two groups that involved lifestyle modification lost =5% or =10% of their initial body weight compared with subjects treated with medication alone (P<0.05 for both comparisons). These results suggest that drug treatment for obesity should only be provided in conjunction with other standard weight management approaches; drug treatment alone exposes patients to the full risks and costs of treatment without the full benefits.
Wadden TA, Berkowitz RI, Sarwer DB, et al. Benefits of lifestyle modification in the pharmacologic treatment of obesity. A randomized trial. Arch Intern Med 2001;161:218-227.
70. Side Effects of Sibutramine Hypertension occurs in minority but must be monitored
Somnolence and fatigue
Mood effects - depression and rebound depression ?
GI effects: unsettled stomach, stomach pains, bowel habit alterations
71. Who To consider for Sibutramine Ready to make long term change
Committed to a program of food and activity choice modification
Needing help to stay with the program
No other serotonergic drugs (prozac etc.)
Complaints of struggling with overwhelming appetite or craving?
72. Orlistat - Mechanism of Action ICO / EASD Slide #46
ICO / EASD Slide #46
73. Orlistat inhibits absorption of approximately 30% of dietary fat Fecal fat as an endpoint
Obese 1800 calories, 60 grams
120 mg tid
Rapid onset of effects and rapid cessation
Led to dose modellingFecal fat as an endpoint
Obese 1800 calories, 60 grams
120 mg tid
74. Orlistat: Weight Loss and Maintenance Over 2 Years Orlistat works by inhibiting absorption of about 30% of dietary fat from the gut
Orlistat is a pancreatic lipase inhibitor taken 3 times daily in conjunction with a low-calorie diet and multivitamin supplement
After 1 year of treatment, statistically significantly more weight was lost with orlistat treatment compared with placebo
10.3 kg, orlistat (10.2%)
6.1 kg, placebo (6.1%)
P<0.001, vs placebo
During year 2, patients who continued with orlistat regained about half as much weight as patients switched to placebo
~1.25 kg, orlistat
2.5 kg, placebo
P<0.001, vs placebo
Calories derived from protein and carbohydrates are not affected by orlistatOrlistat works by inhibiting absorption of about 30% of dietary fat from the gut
Orlistat is a pancreatic lipase inhibitor taken 3 times daily in conjunction with a low-calorie diet and multivitamin supplement
After 1 year of treatment, statistically significantly more weight was lost with orlistat treatment compared with placebo
10.3 kg, orlistat (10.2%)
6.1 kg, placebo (6.1%)
P<0.001, vs placebo
During year 2, patients who continued with orlistat regained about half as much weight as patients switched to placebo
~1.25 kg, orlistat
2.5 kg, placebo
P<0.001, vs placebo
Calories derived from protein and carbohydrates are not affected by orlistat
76. Side Effects of Orlistat Fat malabsorption
Diarrhea - severity generally related to amount of fat eaten
Fecal Incontinence
Abdominal discomforts: bloating, pains, etc.
Mild malabsorption of fat soluble vitamins (like A, E) - which can be overcome by oral supplementation
77. Who To Consider for Orlistat Ready to make long term change
Committed to a program of food and activity choice modification
Needing help to stay with the program
Those with drugs or conditions that limit sibutramine: depression Rx, serious CV, etc
Willing to tolerate some inconvenience
78. Phentermine: Dosage Dosage
Short term
Tolerance develops after a few weeks, after which drug should be discontinued
Available Dosage
HCL: 15, 18.75, 30, 37.5 mg
Resin: 15, 30 mg
Recommended Initial Dosage
HCL: 15 or 18.75 mg two hours after breakfast
Resin: 15 mg before breakfast
79. Phentermine: Efficacy
80. Phentermine: Adverse Effects Dry mouth
Constipation
Sleep disturbance
Increased blood pressure
81. Phentermine: Safety Possibility for dependence
May increase blood pressure
82. Endogenous cannabinoid blockers -Rimonabont et al. Likely act on Hedonic/Limbic mechanisms
Weight loss studies appear to be in 10% initial BW range
Animal studies indicate combinations may be effective
