obesity in adults: treatment and management

© 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


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.


Treatment of Obesity

Behavioral

Pharmacological

Surgical

Self help programs and books


Behavioral Treatment Philosophy

Consists of a set of principles and techniques to modify eating and activity habits.

Emphasizes small and sustainable changes.


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


Behavioral Treatment Methods

Self-monitoring Recording food intake/evaluating nutrients

Recording physical activity

Stimulus control techniques Time

Place

Activity

Sight/smell

Emotions


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.


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


Behavioral Treatment Results

10% reduction over 20 to 24 weeks

33% regain at one year

More weight regained over time


Improving Weight-loss Maintenance

Continued care

Sustaining dietary changes

Exercise

Pharmacotherapy


Treatment of ObesityPharmacological Therapy

Pharmacological interventions to facilitate weight loss and behavior change include: Enhancing satiety

Decreasing fat absorption

Increasing energy expenditure

Decrease appetite


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


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.


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


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.


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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Orlistat

Orlistat (Xenical)Summary of Research Findings

Sjostrom L et al. Lancet 1998;352:167-172.


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


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.


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.


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.


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


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


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.


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


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.


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.


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


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.


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.


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.


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.


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.


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).


Improving Weight-loss Maintenance

Continued care

Exercise

Pharmacotherapy

Other


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


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.


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.


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.


Results

Defined Weights % Reduction

Dream 38%

Happy 31%

Acceptable 25%

Disappointed 17%

Foster GD, et al. J Consult Clin Psychol 1997;65:79-85.


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.


Helping Patients Accepts More Modest Weight Loss

Be clear about what treatment can and cannot do.

Discuss biological limits.

Focus on non-weight outcomes.

Be empathic about dissatisfaction with weight and shape.

obesity in adults: treatment and management

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