© 2000 university of pennsylvania school of medicine gary d. foster, phd clinical director, weight...
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© 2000 University of Pennsylvania School of Medicine
Gary D. Foster, PhD
Clinical Director, Weight and Eating Disorders ProgramAssistant Professor, Department of PsychiatryUniversity of Pennsylvania School of Medicine
Obesity in Adults:Treatment and Management
© 2000 University of Pennsylvania School of Medicine
Objectives
Describe the efficacy of the following for the treatment of obesity: Behavioral methods
Pharmacological therapy
Surgical approaches
Identify the pros and cons of self-help diets for the treatment of obesity.
Review new guidelines for successful outcomes in obesity treatment.
© 2000 University of Pennsylvania School of Medicine
Treatment of Obesity
Behavioral
Pharmacological
Surgical
Self help programs and books
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Behavioral Treatment Philosophy
Consists of a set of principles and techniques to modify eating and activity habits.
Emphasizes small and sustainable changes.
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Behavioral Treatment Methods Identifying Patterns
Buy chips
Leaves chips on table
Come home from work, tired and hungry
See kids eating chips
Eat several handfuls of chips standing up
Feel guilty
Finish bag of chips
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Behavioral Treatment Methods
Self-monitoring Recording food intake/evaluating nutrients
Recording physical activity
Stimulus control techniques Time
Place
Activity
Sight/smell
Emotions
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Behavioral Treatment Methods Rationale for Increasing Physical Activity
Associated with significant health benefits.
Single best predictor of weight maintenance.
Not associated with short-term weight loss.
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Behavioral Treatment Methods Increasing Physical Activity
Identify barriers Lack of time
Lack of motivation
Increased safety concerns
Prescribe small changes Take the stairs
Gardening
Walking during work
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Behavioral Treatment Results
10% reduction over 20 to 24 weeks
33% regain at one year
More weight regained over time
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Improving Weight-loss Maintenance
Continued care
Sustaining dietary changes
Exercise
Pharmacotherapy
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Treatment of ObesityPharmacological Therapy
Pharmacological interventions to facilitate weight loss and behavior change include: Enhancing satiety
Decreasing fat absorption
Increasing energy expenditure
Decrease appetite
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Sibutramine (Meridia) Mechanism of Action
Serotonin and norepinephrine re-uptake inhibitor (SNRI).
Animal research data shows drug reduces body weight by: Decreasing food intake in rats
Stimulates thermogenesis in rats
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Sibutramine (Meridia) Summary of Research Findings
6% to 8% weight loss with 10 to 15 mg/day.
2% weight loss with placebo.
Published data available up to one year.
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Sibutramine (Meridia)Summary of Reported Adverse Event
Package insert data, Sibutramine, 1998.
Percent (%) of Patients
Adverse Event Placebo (n = 884) Sibutramine (n=2068)
Dry mouth 4 17
Anorexia 4 13
Constipation 6 12
Insomnia 5 11
Appetite increase 3 9
Dizziness 4 7
Nausea 3 6
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Sibutramine (Meridia) Prescribing Information
For patients with BMI > 30 or > 27 in the presence of risk factors.
5 to 15 mg per day.
Not for patients on SSRIs (e.g. Paxil, Zoloft, Prozac)
Not for patients with poorly controlled hypertension, history of coronary artery disease, CHF, arrhythmia or stroke.
Regular BP and heart rate monitoring required.
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Orlistat (Xenical): Mechanism of Action
Activity occurs in the stomach and small intestine.
Inhibits gastric and pancreatic lipases.
30% of ingested fat is unabsorbed and excreted.
Minimal systemic absorption.
Low-fat diet ( 30%) required to minimize side effects.
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Time (years)
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Placebo
Orlistat
Orlistat (Xenical)Summary of Research Findings
Sjostrom L et al. Lancet 1998;352:167-172.
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Orlistat (Xenical)Summary of Reported Adverse Events
Package insert data, Orlistat, 1998.
Adverse EventsOverall Incidence(% of Patients)
Oily spotting 26.6
Flatus with discharge 23.9
Fecal urgency 22.1
Oily stool 20.0
Oily evacuation 11.9
Increased defecation 10.8
Fecal incontinence 7.7
© 2000 University of Pennsylvania School of Medicine
Orlistat (Xenical)Prescribing Information
120 mg TID with meals containing fat.
Patients should be on a nutritionally balanced, low-fat diet (< 30%) to minimize side effects.
Prescribe multivitamin to be taken at least two hours before or after the medication.
Orlistat is contraindicated for pregnant or lactating women, and those with chronic malabsorption syndromes or cholestasis.
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Chronic Pharmacological Treatment and Challenges
Similar to pharmacotherapy of other chronic conditions.
Consistent weight gain seen when medications are discontinued.
Requires intensive risk/benefit analysis and careful patient selection.
Safe and effective medications.
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Surgical Treatment of Obesity Patient selection criteria
BMI > 40 or > 35 for those with weight related co-morbidities.
History of failed conservative weight loss approaches. No substance abuse and/or psychiatric disorders.
Surgical options Vertical banded gastroplasty (VBG) Gastric bypass (GBP)
Outcomes Weight loss is 25% to 35% of initial weight. Weight loss is generally well maintained. Significant improvement in co-morbidities.
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Surgical Treatment of ObesityVertical Banded Gastroplasty (VBG)
Formation of small proximal gastric pouch.
Restricts amount of food without bypassing the gut.
Delays gastric emptying.
Creates feeling of early satiety.
Band
Pouch
Staple Line
Fundus
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Surgical Treatment of Obesity Gastric Bypass
Formation of 20-30 ml proximal gastric pouch.
Delays gastric emptying.
Interferes with absorption of nutrients.
May induce dumping syndrome after high carbohydrate meal.
Staple Line
Fundus
Jejunum
Pouch
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Treatment of ObesityPopular Weight Loss Diets
Low-calorie diets Calorie deficit allows for 1 to 2 pound weight loss/week
Nutritionally balanced food plan (15% protein, 30% fat, 55% carbohydrate)
Weight Watchers, Jenny Craig
High protein, low carbohydrate diets Emphasis can vary between unrestricted sources of protein
and consumption of only lean sources (chicken, fish).
Dr. Atkins’ New Diet Revolution, The Zone, Sugar Busters.
© 2000 University of Pennsylvania School of Medicine
Treatment of ObesityPopular Weight Loss Diets
Low-calorie diets Weight Watchers
Jenny Craig
Low-carbohydrate diets Dr. Atkins’ New Diet Revolution
The Zone
Sugar Busters
© 2000 University of Pennsylvania School of Medicine
Low-Calorie Diets
Usually provide a total calorie deficit to allow for 1 to 1 1/2 pounds of weight loss per week.
Rely on use of fat-free and low-fat foods.
Balanced nutritional food plan. (15% protein, 30% fat, 55% carbohydrate)
Mulitvitamin/mineral supplement recommended.
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Commercial Programs Weight Watchers
Traditional program includes a balanced low calorie diet containing 1200 calories per day for women; 1800 calories for men.
Offers a flexible 1-2-3 program which enables you to eat whatever you want using a point system which are determined based on your weight loss goals.
Priced reasonably; approximately $12.00 per visit.
Weekly “weigh-ins” and purchasing your own food.
Group meetings lead by successful program graduates which provide support and advice on behavior modification, exercise, and nutrition.
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Commercial Programs Jenny Craig
Offers several programs to meet individual needs
Provides weekly planned menus which are nutritionally balanced
Menus feature Jenny Craig packaged foods which can cost approximately $65 - $75 per week
Offers convenience for the person who does not cook
Calorie levels range from 1000 - 2300 calories/day
Provides basic strategies for managing stress and physical activity
Staff not medically trained
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Dr Atkins’ Diet Book
• High protein diet.
• To identify methods to assess the nutritional status of healthy patients as well as those with acute or chronic illness.
• To identify risk factors and usual physical findings associated with malnutrition and determine who would benefit from additional nutrition counseling.
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Atkins Diet: The Rules of the Induction Diet (14 days)
• Diet consists of pure proteins and fat with < 20 grams carbohydrates per day.
• Sample menu:
Breakfast: Ham, cheese, mushroom omelet with bacon or smoked fish with cream cheese.
Lunch: Chef salad with ham, chicken, cheese, eggs, creamy Italian dressing or bacon cheeseburger- no bun.
Dinner: rack of lamb, salmon or chicken and salad.
Dessert: assorted cheeses or diet Jello with heavy cream.
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Biochemical Aspects of the Atkin’s Diet
• No more than 20 grams of carbohydrates/day so that insulin levels are decreased.
• Low insulin/glucagon (IG) ratio results in fatty acid oxidation and gluconeogenesis for energy.
• Goal is to achieve ketosis/lipolysis.
• High protein diet needed to preserve lean body mass (muscle protein) however there is always a state of low protein synthesis due to low IG ratio.
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Metabolic Effects of Low Carbohydrate Diets
Significant reduction in caloric intake.
Significant reduction in B vitamins and fiber intake.
Increased ketone formation if severe CHO restriction.
High saturated fat diet clearly shown to increase serum LDL levels and risk of CVD.
No long-term studies on weight change (-/+) or effects on serum glucose or LDL levels.
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Zone Diet Book by Barry Zears, PhD
• Ideal ratio of carbohydrate, fat, and protein is 40, 30, 30, respectively.
• All meals and snacks should be composed of this nutrient ratio.
• Can purchase meals, beverages, snack bars providing correct nutrient ratio.
• Based on the fact that carbohydrates stimulate insulin secretion which in turn causes excess calories to be converted to fat.
• Emphasizes low fat proteins such as chicken and fish.
• Avoidance of caffeine is recommended.
• Calculating correct amount of protein, fat, and carbohydrate per meal can be time consuming.
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Sugar BustersDrs. Rachael and Richard Heller
• Follows the basic diet plan of Dr. Atkins’ high protein, low carbohydrate diet, emphasizing lean meats.
• Focus is on avoiding refined carbohydrates such as sugar and white rice.
• Diet allows one reward meal each day in which carbohydrates are permitted.
• Avoids food eaten in combination (i.e. fruits should not be eaten with meat dishes).
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Improving Weight-loss Maintenance
Continued care
Exercise
Pharmacotherapy
Other
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Weight Change: Former Criteria for Success
Reduction to ideal body weight.
Reduction of 50% of excess weight.
Reduction to upper limit of “normal” body fat
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Reasons for Abandoning Ideal Weight with Significantly Overweight People
Most cannot achieve ideal weight, even with most aggressive approaches.
Most cannot maintain losses >15% of initial body weight without surgery.
Losses of 5% to 10% of body weight are associated with significant health improvements.
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Weight Change New Criteria for Success
According to the Institute of Medicine’s report, Weighing the Options: Successful long-term weight control by our definition means
losing at least 5% of body weight and keeping it below our definition of significant weight loss for at least one year.
Weight loss of only 5% to 10% of body weight may improve many of the problems associated with overweight, such as high blood pressure and diabetes.
Thomas P (ed). Weighing the Options. Washington, DC: IOM, National Academy Press,1995.
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What Is A Reasonable Weight Loss ? Patients’ Expectations and Evaluations of
Obesity Treatment and Outcome
Study design 60 obese women, age 40 + 8.7 yrs.
BMI 36.3 + 4.3 kg/m2
Subjects questioned about their goal weight Dream weight
Happy weight
Acceptable weight
Disappointed weightFoster GD, et al. J Consult Clin Psychol 1997;65:79-85.
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Results
Defined Weights % Reduction
Dream 38%
Happy 31%
Acceptable 25%
Disappointed 17%
Foster GD, et al. J Consult Clin Psychol 1997;65:79-85.
© 2000 University of Pennsylvania School of Medicine
Percent Achieving DefinedWeight at Week 48 (n=45)
Dream = 0%
Did not Reach Disappointed Weight 47%
Disappointed 20%
Acceptable 24%
Happy9%
Weight loss: 16.3 ± 7.2 kg
Foster GD, et al. J Consult Clin Psychol 1997;65:79-85.