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Treatment of Obesity

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Title: Treatment of Obesity


1
Treatment of Obesity
  • Pennington Biomedical Research Center
  • Division of Education

2
Treatment options
  • When does obesity threaten the health and life of
    a patient?
  • Which patients have co-morbidities that make an
    aggressive treatment necessary?

3
Steps in determining treatment
  • Determine BMI.
  • Assess complications and risk factors

4
Steps in determining treatment
  • Determine BMI-related health risk
  • Determine weight reduction exclusions
  • Mental illness
  • Unstable medical condition
  • Some medications
  • Temporary
  • Pregnancy or lactation

5
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

6
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
7
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.

8
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.

9
Dieting with the Exchange List
  • Food is broken down into 6 categories
  • Starch/Bread
  • Meat
  • Vegetables
  • Fruit
  • Milk
  • Fat

10
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.

11
Exchanges for Various Calorie Levels
Total Kcal/d 1200 1400 1500 1600 1700 1800 2000 2100 2200
Meat 4 4 5 6 6 6 6 6 6
Bread/ starch 5 7 7 7 8 9 10 11 11
Vegs 2 3 4 2 2 2 2 2 3
Fats 3 3 3 3 3 4 4 4 4
Fruit 3 3 3 3 3 3 3 3 4
Skim milk (cups) 2 2 2 - - - - - -
2 milk 2 2 2 2 2 3
12
Example of daily exchange diet 1800 Kcals daily
BREAKFAST
  • 1 c orange juice
  • 2 slices of toast
  • 1 hard-cooked egg
  • 2 tsp margarine
  • 1 c 2 milk
  • Coffee or tea
  • 2 Fruits
  • 2 Breads
  • 1 Meat
  • 2 Fat
  • 1 Milk
  • Free Food

Yields
13
Example of daily exchange diet 1800 Kcals daily
LUNCH
  • ½ c tuna
  • 2 slices whole wheat bread
  • ½ c tomato slices
  • Lettuce/cucumber salad
  • 1 c sliced peaches
  • 1 tsp margarine
  • Tea with lemon
  • 2 Meat
  • 2 Bread
  • 1 Vegetable
  • Raw Vegetable
  • 2 Fruit
  • 2 Fat
  • Free Foods

Yields
14
Example of daily exchange diet 1800 Kcals daily
  • 3 oz baked chicken
  • ½ c mashed potato
  • 1 small whole grain roll
  • ½ c broccoli, ½ c carrots
  • Tossed salad
  • 1 Tbsp salad dressing
  • 1 tsp margarine
  • Coffee
  • 3 meat
  • 1 Bread
  • 1 Bread
  • 1 Vegetable
  • Raw Vegetable
  • 1 Fat
  • 1 Fat
  • Free Food

DINNER
Yields
15
Example of daily exchange diet 1800 Kcals daily
EVENING SNACK
  • 2 graham crackers
  • 1 c 2 milk
  • 1 Bread
  • 1 Milk

16
The Exchange Diet
  • For more information please visit
  • http//www.diabetes.org/home.jsp

17
Dieting Using Calorie Controlled Portions
  • 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

18
Meal Replacement Plan
  • 4 types of meal replacers
  • Powder mixes
  • Shakes
  • Bars
  • Prepackaged Meals

19
Meal Replacement Plan
  • An intake of five fruits and vegetables is
    recommended.
  • Effective
  • Convenient
  • Nutritionally balanced

20
ExampleA 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
21
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

22
Exercise
  • Children at least 60 minutes, and up to several
    hours of physical activity per day for children
    and adolescents
  • Several bouts of physical activity lasting 15
    minutes or more each day

23
Exercise
  • Energy Balance maintaining weight.
  • Positive energy balance leads to weight gain.
  • Negative energy balance leads to weight loss.

24
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.

25
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.

26
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
  •    Swimming
  •       Aerobic dancing
  •       

Racket sports   Lawn mowing   Ice or roller
skating Using aerobic equipment (treadmill,
stationary bike)
27
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.

28
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.

29
VLCD Facts
  • Not recommended for pregnant or breastfeeding
    women
  • Not appropriate for children or adolescents
  • Not recommended for older individuals

30
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

31
Group Approaches
  • Social support
  • integration into social network and positive
  • interactions with others.
  • Individual feels support, acceptance, and
    encouragement by others.

32
Behavior Treatment
  • Need to change ones approach
  • thinking
  • feelings
  • actions
  • to eating and physical activity.

33
Behavioral targets
Total energy intake
Total energy expenditure
_
Weight

Eating
Activity
Targets of behavioral therapy
34
Behavior Therapy Important Components
  • Making Lifestyle Change a Priority
  • Establishing a Plan for Success

35
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.

36
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.

37
Behavior Therapy Important Concepts
  • 5. Avoiding a Food Chain Reaction
  • Stimulus control.
  • Learning to recognize cues.

38
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

39
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

40
Behavior Therapy Important Concepts
  • Changing Eating and Activity Patterns
  • Programmed exercise vs lifestyle
  • Lifestyle activity preferable for weight loss.

41
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

42
Behavior Therapy Important Concepts
  • 8. Cognitive Behavioral Strategies
  • Traditional behavioral treatment components with
    emphasis on thinking patterns that may affect
    eating behaviors.

43
Behavior Therapy Important Concepts
  • 9. Stress Management
  • Stress is a primary predictor of overeating and
    relapse.
  • Stress management skills

44
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
45
Drug Therapy
  • Commonly prescribed drugs for the treatment of
    obesity include
  • Phentermine
  • Sibutramine
  • Orlistat

46
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.

47
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.

48
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.

49
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

50
Types of GI surgeries available
  • Restrictive
  • Malabsorptive
  • Combined restrictive/malabsorptive

51
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.

52
Restrictive Operations Examples
  • Adjustable gastric banding
  • A band is clamped to create a pouch.


53
Restrictive Operations Examples
  • 2. Vertical banded gastroplasty.
  • Uses the band and staples to create
  • a small pouch. Not commonly used
  • today.

54
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.

55
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 patients willingness to
    adopt a healthy lifestyle.

56
Restrictive Operations Risks
  • Overeating leading to vomiting.
  • Break in tubing.
  • Problems leading to a second operation.
  • These risks need to be taken into account by any
    individual considering the surgery!

57
Malabsorptive Operations
  • The main malabsorptive operation is the
    jejunoileal bypass which is not performed today
    because of the high incidence of health
    complications.

58
Combined Restrictive and Malabsorptive Operations
  • 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.

59
Combined Restrictive and Malabsorptive Operations
  • Biliopancreatic diversion (BPD)
  • Remove portion of stomach.
  • Connect this directly to the
  • final segment of the small intestine
  • completely bypassing sections of
  • intestines.

60
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.

61
Combined Operations Disadvantages
  1. Can be difficult.
  2. May result in long-term nutritional deficiencies.
  3. Decreased absorption of iron and calcium.
  4. Require fat soluble vitamin supplementation.
  5. May have dumping syndrome.

62
Combined Operations Risks
  1. May lead to complications.
  2. Greater risk for abdominal hernias.
  3. The risk of death may be higher.

63
Bariatric Surgery Facts
  • Procedures cost from 20,000 to 35,000.
  • Medical insurance coverage varies by state.

64
NIDDK (National Institute of Diabetes and
Digestive and Kidney Diseases)
  • The patient should consider the following
    questions prior to weight loss surgery
  • Are you unlikely to lose weight or keep weight
    off long-term with non-surgical measures?
  • Are you well informed about the surgical
    procedure and the effects of treatment?
  • Are you determined to lose weight and improve
    your health?

65
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?

66
Conclusions
  • When there are no complications or co-morbidities
    associated with obesity, dietary, exercise and
    behavioral approaches are the safest and best
    approaches.
  • For successful weight loss to become permanent,
    an individual has to adopt new behaviors to
    maintain weight loss.

67
Conclusion
  • It is very important for individuals considering
    initiation of weight loss drug therapy or
    surgeries to be well aware of the risks
    associated with the treatments.
  • Once all risks are understood, then ultimately it
    is the individuals decision to go along with the
    treatment or not.

68
References Behavior Therapy and VLCD Information
  • http//www.medhelp.org/NIHlib/GF-390.html
  • Foreyt, J.P., Poston, W.S.C., Jr. (1998a). The
    role of the behavioral counselor in obesity
    treatment. J Am Diet Assoc, 10(Supplement 2),
    S27-S30
  • Foreyt, J.P., Poston, W.S.C., Jr. (1998b). What
    is the role of 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

69
References Behavior therapy
  • Poston, W.S.C., Jr., Hyder, M.L., O'Byrne, K.K.,
    Foreyt, J.P. (2000). Where do diets, exercise,
    and behavior modification fit in the treatment of
    obesity? Endocrine, 13(2), 187-192.
  • Wadden, T.A., Sarwer, D.B., Berkowitz, R.I.
    (1999). Behavioural treatment of the overweight
    patient. Baillieres Best Pract Res Clin
    Endocrinol Metab, 13(1), 93-107.
  • Wing, R.R. (1993). Behavioral approaches to the
    treatment of obesity. In G. Bray, C. Bouchard
    P. James (Eds.), Handbook of Obesity (pp.
    855-873). New York Marcel Dekker, Inc.
  • Wing, R.R., Tate, D.F. (2002). Behavior
    modification for obesity. In J.F. Caro (Ed.),
    Obesity. http//www.endotext.org/obesity/index.htm

70
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.

71
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.

72
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 12789-798,
    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.

73
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
    Aug134(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 Aug13(Suppl)S146.
  • http//www.slim-fast.com/plan/index.asp?bhcp1
    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.

74
Pennington Biomedical Research CenterDivision
of Education
  • Heli J. Roy, PhD, RD
  • Beth Kalicki
  • Division of EducationPhillip Brantley, PhD,
    DirectorPennington Biomedical Research
    CenterClaude Bouchard, PhD, Executive Director

Edited October 2009
75
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, Alzheimers 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.  
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