4 pillars of obesity treatment

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The Four Pillars of Obesity TreatmentRYAN MORGAN, DO, FACOI, DIPL. ABOM, DIPL. ABCLPRESIDENT OF VITALIS METABOLIC HEALTH

Disclosures

Faculty member for Rhythm Pharmaceuticals Involved in various clinical trials: Novavax,

Moderna (none involving weight)

ObjectivesReview necessary components of screening and

evaluation for obesityDiscuss brief overview of pharmacologic

intervention, including FDA approved medications and off-label usage

Reinforce when medical or surgical referrals are appropriate

How to write a proper physical activity prescription

Review dietary approaches and adviceDiscuss a general overview of how to implement

behavioral approaches into encounter

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Approaching Weight

References 1 & 2

1Massachusetts General Hospital, Boston, MA, 2Queen Mary Hospital, The University of Hong Kong, 3George Washington University, Washington, DC

Michele M. Yuen1,2, Rebecca L. Earle1, Nitya Kadambi1, Joseph Brancale1, David T. Lui2, Scott I. Kahan3, Lee M. Kaplan1

reveals 236 obesity‐associated disorders (ObAD)

Methods I

Conclusions and Implications

Contacts

• Obesity is linked to over 200 discrete disorders

• This number is far greater than previously reported

• The diseases that obesity is linked to comprise 35% of non‐fatal global burden of disease and 38% of causes of global causes of death based on data from 2015 (retrieved from http://www.healthdata.org/gbd)

• This methodology provides a framework for further study to more precisely define these clinical relationships and to explore their pathophysiological basis and health policy implications.

Generated list of candidate ObAD based on a prioriknowledge

Searched PubMed using MeSH terms with Boolean logicExample: comorbidity/epidemiology[MAJR] AND

obesity/epidemiology[MeSH]

Narrowed or broadened search by adding or removing MeSH terms

1 or more articles reporting an OR, RR or HR

No report of OR, RR or HR

Methods II

Modified Grading of Recommendations Assessment, Development & Evaluation (GRADE)

Consider study design

Randomized controlProspective cohort with control

starting grade = 4

Other (ie. observational)starting grade = 2

Reasons to grade UP:• Large magnitude of effect• Dose‐response gradient is present

• Presence of plausible cofounders (i.e., residual confounding that would result in an underestimate of effect)

• Time component in study design (e.g. retrospective cohort)

Reasons to grade DOWN:• Study limitations / risk of bias (e.g. failure to develop and apply appropriate eligibility criteria, flawed measurement methods, failure to control confounding variables, incomplete follow‐up)

• Inconsistency of effects• Indirectness of outcome• Imprecision

Background

Aims

The breadth of comorbid conditions associated with obesity has not been comprehensively described. Using a systematic approach, we performed an extensive, systematic review of the literature to evaluate the extent of obesity‐associated disorders (ObAD).

• To assess the relationship between the severity of obesity, using body mass index (BMI) categories and waist circumference (WC) as measures, and the risk of having the ObAD (manuscript in preparation)

• To assess the population‐attributable risk of obesity in the major ObAD (manuscript in preparation)

• To assess the benefit of weight loss (to be addressed in Part 2 of this study)

• To evaluate the strength of evidence of the association between obesity and each ObAD using a modified Grading of Recommendations Assessment, Development & Evaluation (GRADE) approach

• 236 ObAD were identified

• ‐100 relevant, high‐quality articles each) were observed for cardiovascular disorders, cancers, selected infections, obstetric conditions

• Moderate associative evidence (10‐50 articles each) was found for GI, renal, orthopedic, psychiatric and dental disorders

• Weak evidence (<10 qualifying articles) was identified for hematological, pulmonary, neurological, rheumatological, ENT, surgical and ophthalmological ObAD

• Weakest evidence (10‐50 cross‐sectional studies) was found for quality of life disturbances and dermatological ObAD

ResultsFigure: Strength of evidence for each of the 236 ObAD

• ObAD are clustered by discipline and organ system affected (if applicable)

• Size of the dot represents number of article retrieved for the individual ObAD.

• Color of the dot represents the highest GRADE of retrieved articles

Color GRADE

Strength of

evidence

4 Very strong

3 Strong

2 Moderate

1 Weak

Contributors to Weight Gain Medical issues/Medication Media Social pressures Socioeconomic status Exercise Food accessibility Energy Density Sleep Quality Sleep Duration Leisure time/play

Endocrine disrupters Epigenetics Genetics Antibiotic exposure Improving technology Work activities Habits Emotional state/Stress/Mental

Health

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Reference 3

Material provided and approved for use by the © Obesity Medicine Association.

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Assessment and Evaluation

Family HistoryGeneticsEpigeneticsSocio-economic

upbringing Screening

Eating DisordersSleep DisordersMood Disorders

Prior weight loss efforts ROS Physical Exam Body Composition Labs

CMP, CBC, TSH, A1c, Lipid Profile, fasting insulin level, microalbumin, β-hCG

References 4 & 5

Drug ClassWeight Gain Drug Class Weight Gain

Anti‐ depressants

Amitriptyline Mirtazapine Paroxetine MAOI Lithium

Migraine prevention agents

Beta‐blockers

Anti‐hyperglycemic

Insulin Sulfonylureas

TZDs Meglitinides

Seizure Control medications

Valproate

Anti‐hypertensive agents

Beta‐blockersImmuno‐

suppressantsGlucocorticoids

Atypical antipsychotic agents &

Mood stabilizers

Clozapine Olanzapine Lithium

Gabapentin

AntihistaminesDiphenhydramine

Hydroxyzine Cetirizine Fexofenadine

Reference 6

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Hypoxia-> insulin resistance Chronic shorter sleep-> decreased leptin and

increased ghrelin Less energy -> decreased energy expenditure

Sleep Apnea

Reference 47

Binge Eating Disorder In a behavioral weight loss (BWL) study, those with CBT +

BWL lost more than CBT alone, whereas BWL had least remission in binging episodes.

Energy density education better outcomes than general nutrition education

Lisdexamfetamine is only approved medication for moderate to severe BED. Could worsen bipolar disorder and RCI in h/o addiction.

Topiramate is used off-label for BED. Weight loss with education.

References 40-46

Night Eating Syndrome (NES)

Suspected to be a shift in circadian rhythm Gold standard is CBT Rx: SSRIs, melatonin, topiramate No FDA-indicated medication Sertraline DOC Bright light therapy may help Insomnia medication contraindicated

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Material provided and approved for use by the © Obesity Medicine Association

Surgery IndicationsASMBS

Inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts

BMI > 35 with at least one or more obesity‐related co‐morbid condition (T2DM, HTN, OSA, OHVS, NAFLD, OA, Dyslipidemia, GI dx, or CHD)

BMI > 40, or more than 100 pounds overweight

OMABMI 30‐34.9 with one or more AHC*

BMI > 35 with one or more AHC

BMI > 40 with or without AHCReferences 7 & 8

RM1

Pros Cons Expected loss in % excess body Wt @ 2

yrs

Optimally suited for pts with

Roux‐en‐y Gastric Bypass

> Improvement in metab. disease

^ risk of malabsorptive complications

60‐75% Higher BMI, GERD, T2DM

Vertical Sleeve Gastrectomy

Improves metab. disease; maintains Sm. Int anatomy;

infrequent nutrient deficiencies

No long‐term data 50‐70% Metabolic disease

Laparoscopic adjustable gastric

banding

Least invasive; removable 25‐40%, 5‐year removal rate internationally

30‐50% Lower BMI, no

metabolic disease

Biliopancreatic diversion with duodenal switch

MOST amount of wt loss and resolution of metabolic

disease

^ risk of nutrient deficiencies over bypass

70‐80% Higher BMI, T2DM

Reference 9

Surgery Types

RM1 E.g. 23 yo, 5' 2" 360 lb female with BMI 65.84 and predicted weightlossRyan Morgan, 5/16/2020

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SymptomsObjective findings

Timing from Surgery

Common Surgery Types

Band erosionpercieves no restriciton/ obstruction, pain, N/V

failure of weight loss ~22 months LAGB

Band obstruction

abdominal pain, reflux, regurgitation of undigested

food post‐prandially

can still gain weight if on liquid calories

variable LAGB (14%)

Marginal Ulcer

abdominal pain +/‐vomiting, stomal stenosis,

GI bleedingvariable

3‐7 days (acute); variable

RNY (0.6‐16%)

Gastro‐gastric fistula

Increased capacity to ingest food, N/V, elevated WBC

associated with marginal ulcer or leak; weight

regain~25‐80 days RNY (0‐3%)

Intestinal SBOabdominal pain, nausea, vomiting, obstipation

N/V, cramping abdominal pain/ inability for passing

flatus or stool

> 6 months out from surgery

RNY

Reference 10

Surgery Complications

Dumping Syndrome

lightheaded, fatigue, reactive hypoglycemia, postprandial diarrhea

facial flushing within 18 months RNY (20‐85)

Bleedinglightheaded, weak

a/w perforation; tachycardia,

hypotension, drop in Hgb/Hct, oliguria

within 72 hours and up to 14 days

VSG, RNY

Leak/ performation

severe abdominal painperitonitis on exam; tachycardia, fever, low

urine output

within 72 hours and up to 14 days

RNY, PBD/DS, VSG


Timing from Surgery


Stricture/Stomal Stenosis

post‐prandial epigastric pain with frothy emesis

30% asymptomatic 4‐6 weeks(3‐6 mo) RNY, PBD/DS

Reference 10

Internal Hernia

intermittent post‐prandial pain and/or

emesisassociated with SBO

1 week‐ 3 years (6‐24 mo)

RNY, PBD/DS (tot 0‐5%)

Incisional HerniaPain at 1 or more incisional sites

bulging with valsalva/cough

3‐6 months after surgery

open procedures (20%)

Wound infection

abdominal pain, decreased appetite

excess drainage, fevers, chills, leukocytosis, change in bowel

pattern

<30 days ALL

GB or gallstone disease

epigastric or RUQ pain, nocturnal pain to right

shoulder

elevated ALP/bili/liver enzymes/lipase, leukocytosis

within 6 months ALL (2‐41%)


Timing from Surgery


Reference 10

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Risk of Weight Regain and Long-term Weight Loss Success

Biggest Loser Study: 36% regained back to within 1% of original weight, 57% maintained >10% weight loss at 6 years

DPP: 37% maintained 7% weight loss at 3 years Look AHEAD Study: 27% maintained 10% weight loss at

8 years.

Risk of Weight Regain and Long-term Weight Loss Success

Kraschnewski JL et al: 36.6%, 17.3%, 8.5%, and 4.4% were able to maintain 5%, 10%, 15%, and 20% weight loss, respectively, at one year.

Wing RR, Phelan S: 10-20% able to maintain 5% weight loss at 5 years

Sarwer DB et al: 30-35% of lost weight is regained one year following treatment and 50% of patients will return to baseline by 5th year

NHANES (1999-2006): 1 in 6 adults with overweight/obesity reported maintaining weight loss of at least 10% for 1 year at any point in their lives

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FDA indicated

Anti‐Obesity Medication Common Side‐effects Caveats/ConcernsPhentermine

dry mouth, constipation, insomniaCI: Glaucoma, active CHD, Hyperthyroid, Abuse hx

Phentermine/ Topiramate

constipation, GB stones, nephrolithiasis, paresthesia, cognitive impairment

CI: Pregnancy; active CHD, uncontrolled HTN, hx kidney stones,

hyperthyroidism

Bupropion/ Naltrexone

nausea, headaches CI: Hx of seizures, bulimia, opioid use

Liraglutide/Semaglutide nausea, renal impairment CI: FH medullary thyroid cancer

Orlistat"anal leakage", bloating, urinary oxalate stones, fat‐soluble vitamin deficiency

Avoid: with immunosuppressants, untreated Vit D Deficiency

Diethylpropion dry mouth, constipation, insomniaCI: Glaucoma, active CHD, Hyperthyroid, Abuse hx

Phendimetrazine dry mouth, constipation, insomniaCI: Glaucoma, active CHD, Hyperthyroid, Abuse hx

Reference 11

Non-FDA Indicated

Anti‐Obesity Medication Common Side‐effects Caveats/Concerns

SGLT2‐inhibitors yeast infection, UTI balanitis, amputation

Topiramate cholelithiasis, nephrolithiasis, depression, paresthesia, cognitive

impairment

CI: Pregnancy; active CHD, uncontrolled HTN, kidney stones,

hyperthyroidism

Bupropion palpitations, anxiety, headaches CI: Hx of seizures, bulimia

Other GLP‐1s (excluding high dose Liraglutide and

Semaglutide

nausea, renal impairment CI: FH medullary thyroid cancer

Zonisamide Dizziness, drowsiness, nausea, decreased mental acuity

similar as topiramate as has some carbonic anhydrase inhibition

Metformin diarrhea, flatulence, nausea, bloating can increase topiramate concurrently; lactic acidosis with renal failure

Reference 12


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Energy Expenditure

TDEE = RMR + TEF + NEAT + EPOC + Ex

Medical Clearance

“Cardiac events such as a heart attack or sudden death during physical activity are rare. However, the risk of such cardiac events does increase when a person suddenlybecomes much more active than usual. The greatest risk occurs when an adult who is inactive engages in vigorous-intensity activity (such as shoveling heavy snow). People who are regularly physically active have the lowest risk of cardiac events both while being active and overall.”

Physical Activity Guidelines for Americans, 2nd edition

*If patient DOES or DOES NOT exercise regularly

ACSM’s Guidelines for Ex Testing and Prescription. 10th ed. 2018, pp33-34

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Activity Questions

Previous benefits of physical activity on weight loss or maintenance

Previous and current barriers to physical activity Rating ADLs (special equipment/needs/modifications) Readiness to engage Will medication need to be adjusted (e.g. DM)

RM4

Reference 13

Reference 14

RM4 can't walk: seated exercise program, aquatic exercises, gravity-mediated, PT; limited mobility: walking, swimmingRyan Morgan, 5/21/2020

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Levels of Physical Activity

Reference 15

Reference 16

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Exercise Prescription: FITTE

FrequencyIntensityTimeTypeEnjoyment


Comparing Diets“Overall, weight loss diminished at 12 months among all macronutrient patterns and popular named diets, while the benefits for cardiovascular risk factors of all interventions, except the Mediterranean diet, essentially disappeared.”

“Reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize.”

References 17 & 18

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References 17

Chronobiology 700/500/200 vs 200/500/700 lost 11 more pounds at 12 weeks 50%/30%/20% vs 20%/30%/50% lost ~9 more pounds at 8 weeks 70% kcal at breakfast/lunch vs 55% lost significantly more weight loss Main meal lunch vs dinner lost more weight OGTT in 50 women with PCOS improved when breakfast largest meal

(54/35/11% VS 11/35/54%) Shift work and social jet lag have higher rates of obesity, diabetes, CVD Eating closer to natural dim-light melatonin onset, higher body fat

References 19-26

Breakfast Intervention Study 12 weeks study 1200 calorie diet Weight loss in all groups

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Meal/Snack- No Standard DefinitionsMeal

Self-defined Time of day

6-10 AM (breakfast) 12-3 PM (lunch) 6-9 PM (dinner)

Largest eating occasion during these periods

All eating occasions during these periods

At least 15% total daily energy intake

Snack

Self-defined Outside of times

dedicated for meals Less than largest eating

occasion during periods outside of typical meal times

<15% of total daily energy intake

Eating Occasion

Eating/drinking providing at least 50 kcal

Separate occasions at least 15 min apart

Not based on time of day Meal distinction defined

by participants Meal = or > 15% of total

daily energy intake

Reference 19

Meal Frequency Schoenfeld et al:

Meta-analysis showing increased meal frequency lowered fat mass. Results were lost when single study was removed (Iwao et al). In calorie-controlled conditions, meal frequency did not matter. Proposed mechanism is increased thermic effect of food if association

exists Schwingshackl et al:

Meta-analysis found no statistical significance of meal frequency and weight, but lower meal frequency had smaller waist.

Sievert et al: No weight difference with changes in meal frequency but lower meal

frequency had higher total daily caloric intake. References 27-29

Fasting Fasting before 6PM vs those who eat after 6pm but fast

in AM has been shown to have reduced CRP ADF vs DCR

References 30-32

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IF vs DCR No Difference when calories controlled. Metabolic

benefit

References 30-32


Motivational Interviewing Definition: Collaborative, goal-oriented method of

communication that attends to language of change for the purpose of eliciting, exploring, and strengthening a patient’s own motivation for target behavior change.

Fear = Avoidance Main Reasons for Change:

Change influenced by empathic interactionsPeople who believe they are likely to change do so

Self-perception theoryReference 33

MOU6

MOU6 Microsoft Office User, 6/12/2020

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Spirit of Motivational Interviewing

CAPE Compassion Acceptance – respecting autonomy (vs.

authority) Partnership – collaboration (vs. confrontation) Evocation - pulling from patient (vs. Imposing)

MI Principles/ProcessesPrinciples Empathy Develop Discrepancy/Explore Ambivalence Supporting self-efficacy Roll with resistance (sustain talk) Ignore the righting reflexProcesses Engaging: use OARS (open-ended questions, affirmations, reflections, summaries) Guiding/Focusing: agenda setting (what they want to get out of the interaction) Evoking: selective eliciting the reasons they are here with you Planning: moving to a change plan

MI Hill –Change TalkDARN (Preparatory Change Talk) Desire to change (want, like, wish…) Ability to change (can, could…) Reasons to change (if…then) Need to change (need, have to, go to)

CATS (Mobilizing Change Talk) Commitment to change (intend, decide,

promise…) Activation (willing, ready, preparing…) Taking Steps (started, tried…)

Reference 34

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Types of Behavioral Treatment Cognitive Behavioral Therapy (CBT) – Addresses underlying thoughts and

behaviors

Dialectical Behavioral Therapy (DBT) – Developed for cognitive/ emotional dysregulated patients. Composed of mindfulness, interpersonal effectiveness, emotional regulation, distress tolerance.

Interpersonal Therapy – Can be helpful for those trying to escape discomfort or roles; validated for mood disorders; validated for grief and depression.

Normalized Eating/ Intuitive Eating – All foods fit. Maintenance meal plan and normalize behaviors first before talking about energy density.

Behavioral Weight Loss (BWL) – Lifestyle, exercise, attitudes, relationships, nutrition (LEARN). Gradual lifestyle change, moderate calorie restriction, increase PA.

Acceptance Commitment Therapy (ACT) – Focuses on acceptance, diffusion, contact with the present moment, self as context, values, committed action

References 35-39

Cognitive Behavioral Therapy

Jennifer Shapiro, PhD. Cognitive Behavioral Therapy in Obesity Treatment. OMA. April 04, 2018.

CBT Core Beliefs

Jennifer Shapiro, PhD. Cognitive Behavioral Therapy in Obesity Treatment. OMA. April 04, 2018.

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Acceptance & Commitment Therapy (ACT)

Niemeier HM, et al. An acceptance-based behavioral intervention for weight loss: A pilot study. Behav Ther. 2012 Jun; 43(2): 427-435.

Questions?

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References1. Talking about obesity with clients: Preferred terms and communication styles of UK pre-registration

dietitians, doctors, and nurses. Swift JA, Choi E, Puhl R, Glazebrook C. Patient education and counseling 91;(2013) 186-191.

2. Patients’ preferred terms for describing their excess weight: discussing obesity in clinical practice. Volger S, Vetter M, Dougherty M, et al. Obesity (silver Spring). 2012 Jan; 20(1): 147-150.

3. Dr. Sicat. OMA 20154. http://www.drsharma.ca/wp-content/uploads/edmonton-obesity-staging-system-staging-tool.pdf5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3185097/6. https://www.aace.com/files/obesity/toolkit/meds_promoting_weight_gain-loss.pdf7. https://oma.cld.bz/2020-Obesity-Algorithm/324/8. https://asmbs.org/patients/who-is-a-candidate-for-bariatric-surgery9. Obesitymedicine.com10. Uptodate.com11. Pharmacological management of obesity: An endocrine society clinical practice guideline.

Apovian CM, Aronne LJ, Bessesen DH, et al. The journal of clinical endocrinology & metabolism, volume 100 (2):342-362 with correction 100(5)2135-2136.

References12. Off-label drugs for weight management. Hendricks EJ. Diabetes, metabolic syndrome and

obesity: Targets and therapy. 10: 223-23413. Four-year weight losses in the look ahead study: factors associated with long-term success.

Wadden TA et al. Obesity. 2011.(10):1987-98.14. Four-year weight losses in the look ahead study: factors associated with long-term success.

Wadden TA et al. Obesity. 2011.(10):1987-98.15. Appropriate physical activity intervention strategies for weight loss and prevention of weight

regain for adults. ACSM with Donnelly JE, et al. Medicine & science in sports and exercise. 2009:459-471.

16. ACSM’s Guidelines for Exercise Testing and Prescription, 10th edition17. Comparison of dietary macronutrient patterns of 14 popular named dietary programmes for

weight and cardiovascular risk factor reduction in adults: systematic review and network meta-analysis of randomised trials. GE L, et al. BMJ. 2020;369:m696.

18. Sacks FM, Bray GA, Carey VJ, et al. Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N Engl J Med 2009;360: 859-873.

19. Marie-Pierre St-Onge, PhD. Meal frequency & timing: Implications for health. OMA 2018

References20. Jakubowicz D, et al. High caloric intake at breakfast vs. dinner differentially influences weight loss of overweight

and obese women. Obesity (silver Spring). 2013:2504-12.21. Raynor HA, Li F, Cardoso C. Daily pattern of energy distribution and weight loss. Physiology and behavior. 2018;

192:167-172.22. Lombardo M, et al. Morning meal more efficient for fat loss in a 3-month lifestyle intervention. 2014; 33(3):198-205.23. Madjd A, et al. Beneficial effect of high energy intake at lunch rather than dinner on weight loss in healthy obese

women in a weight-loss program: a randomized clinical trial. The American Journal of Clinical Nutrition. 2016; 104(4):982-989

24. Almoosawi S, et al. Chrono-nutrition: a review of current evidence from observational studies on global trends in a time-of-day of energy intake and its association with obesity. Proceedings of the nutrition society (2015), 75,487-500

25. Jacubowicz D, et al. Clin Sci 2013; 125:423-3226. McHill et al. Am J Clin Nutr 2017; 106:1213-9.27. Schwingshackl L, Nitschke K, Zähringer J, Bischoff K, Lohner S, Torbahn G, Schlesinger S, Schmucker C, Meerpohl JJ.

Impact of Meal Frequency on Anthropometric Outcomes: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Adv Nutr. 2020 Sep 1;11(5):1108-1122.

28. Schwingshackl L, Nitschke K, Zähringer J, et al. Impact of Meal Frequency on Anthropometric Outcomes: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Adv Nutr. 2020;11(5):1108-1122. doi:10.1093/advances/nmaa056

29. Sievert K, Hussain SM, Page MJ, et al. Effect of breakfast on weight and energy intake: systematic review and meta-analysis of randomised controlled trials. BMJ. 2019;364:l42.

8/6/2021

21

References30. Cahill et al, Circulation. 2013; 128: 337-43.

31. Trepanowski et al., JAMA Intern Med. 2017; 177:930-8.

32. Harris et al. JBL database of systematic reviews & implementation reports. 2018.

33. Colleen Fairbanks, PhD. Motivational Interviewing: The Basics. 2018. OMA Conference

34. Damara Gutnick, MD. Motivational interviewing: tips and tools to use in practice. OMA

35. Brownley KA, et al. Binge-eating disorder in adults: a systematic review and meta-analysis. 2016. Annals of internal medicine, 165(6), 409-420.

36. Markowitx JC, Weissman MM. Interpersonal psychotherapy: principles and applications. 2004. World psychiatry, 3(3):126.

37. Vocks S, Tuschen-caffier B, Pietrowsky R, et al. Meta-analysis of psychological and pharmacological treatments for binge eating disorder. Int J Eat Disord. 2010;43:205-217.

38. Masheb RM, Grilo CM, Rolls BJ. A randomized controlled trial for obesity and binge eating disorder: low-energy-density dietary counseling and cognitive-behavioral therapy. 2011. Behaviour research and therapy. 49(12), 821-829.

39. Grilo CM, et al. Cognitive-behavioral therapy, behavioral weight loss, and sequential treatment for obese patients with binge-eating disorder: A randomized controlled trial. 2011. Journal of consulting and clinical psychology, 79(5), 675

References40. Brownley KA, et al. Binge-eating disorder in adults: a systematic review and meta-analysis. Annals of

internal medicine. 2016. 165(6), 409-420.41. Linehan MM. (1993). Cognitive Behavioural therapy of borderline personality disorder. New York:

Guildford.42. Telch CF, Agras WS, Linehan MM. Group dialectical behavior therapy for binge-eating disorder: A

preliminary, uncontrolled trial. 2000. Behavior Therapy, 31, 569-582.43. Telch CV, Agras WS, Linehan MM. Dialectical behavior therapy for binge eating disorder. 2001. Journal

of consulting and clinical psychology, 69, 1061-1065. 44. Rahmani M, et al. The effect of dialectical behavior therapy on binge eating, difficulties in emotion

regulation and BMI in overweight patients with binge-eating disorder: A randomized trial. 2018. Mental health & prevention, 9, 13-18.

45. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). American Psychiatric Pub. https://www.Vyvanse.com/binge-eating-disorder

46. McElroy SL, et al. Topiramate in the treatment of binge eating disorder associated with obesity: a randomized, placebo-controlled trial. American Journal of Psychiatry, 160(2), 255-261.

47. Jehan S, Zizi F, Pandi-Perumal SR, et al. Obstructive Sleep Apnea and Obesity: Implications for Public Health. Sleep Med Disord. 2017;1(4):00019.

4 pillars of obesity treatment

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