1. Weight Management Strategies: Medical and Nutritional Therapy

2. What is Successful Weight Loss?
Common definition: Lose at least 10% of starting weight and keep it off at least one year.

3. What is the Goal of Obesity Treatment?
Specifically, the goal of obesity treatment should be refocused from weight loss alone, which is often aimed at appearance, to weight management, achieving the best weight possible in the context of overall health. –FTC Panel, Commercial Weight Loss Products and Programs What Consumers Stand To Gain and Lose, 1997
accessed

6. Who Should Consider A Weight Management Intervention?
Persons with a BMI of >30
Persons with a BMI between OR a high-risk waist circumference, and two or more risk factors
Persons who are ready to change
NHLBI Obesity Education Initiative. The Practical Guide Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI , 2000.

7. Obesity-Associated Risk Factors: High Absolute Risk
Established coronary heart disease
Other atherosclerotic diseases
Type 2 diabetes
Sleep apnea
NHLBI Obesity Education Initiative. The Practical Guide Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI , 2000.

8. Obesity-Associated Risk Factors: 3 or More = ↑ Risk
Hypertension
Cigarette smoking
High low-density lipoprotein cholesterol
Low high-density lipoprotein cholesterol
Impaired fasting glucose
Family history of early cardiovascular disease
Age (male ≥ 45 years, female ≥ 55 years)
NHLBI Obesity Education Initiative. The Practical Guide Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI , 2000.

9. Other Obesity-Associated Risk Factors
Osteoarthritis
Gallstones
Stress incontinence
Gynecological abnormalities
NHLBI Obesity Education Initiative. The Practical Guide to Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI , 2000.

10. How Much and How Fast?
NIH guidelines recommend a weight loss of .5 to 1 pound/week for persons with a BMI of and 1-2 pounds a week for those with a BMI>35 kg/m2
Allow 6 months to achieve 10% weight loss
After 6 months, focus should shift to weight maintenance for 6 months
Following this, weight loss efforts may resume (NIH, 1998)

11. Weight Loss Goals
R.4.0. Individualized goals of weight loss therapy should be to reduce body weight at an optimal rate of 1-2 lbs per week for the first 6 months and to achieve an initial weight loss goal of up to 10% from baseline.
These goals are realistic, achievable, and sustainable. Strong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

12. Rates of Weight Loss Vary
Men will lose weight faster than women of similar size, due to higher LBM and RMR
A heavier person (who has higher energy needs) will lose weight faster than a smaller person on the same caloric regimen

13. Modest Weight Loss and Health: Diabetes Prevention
A 7% weight loss (mean 15 pounds) through diet and exercise in high risk individuals was associated with a 58% reduction of diabetes incidence in the Diabetes Prevention Program DPP Research Group. N Engl J Med Feb 7;346(6):
An average 7.7 pound weight loss was associated with a 58% reduction in diabetes incidence in high risk individuals in the Finnish Diabetes Prevention study. FDPS Group. N Engl J Med 344:1343–1350, 2001

14. Modest Weight Loss and Health: Hypertension
Weight loss of as little as 4.5 kg (10 pounds) will improve or prevent hypertension in a large segment of overweight persons. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)
Clinically significant long-term reductions in blood pressure and reduced risk for hypertension can be achieved with modest weight loss and increased physical activity. American Dietetic Association Evidence Analysis Library, Hypertension and hyperlipidemia.

15. Modest Weight Loss and Health: Hyperlipidemia
The ATP-III guidelines recommend a 10% weight loss in overweight persons with hyperlipidemia.
A weight loss of ≥2.25 kg was associated with a 40-50% reduction in cardiovascular risk factors in the Framingham Offspring Study (BP, triglyceride, TC, FBS, HDL) Karason K et al. Int J Obes Relat Metab Disord 1999;23:

16. Modest Weight Loss and Health: Diabetes
Calorie restriction and weight loss improves insulin sensitivity and glycemic control in obese patients with Type 2 diabetes. Henry RR et al. J Clin Endocrinol Metab 1985;61:917-25; Kelly DE et al. J Clin Endocrinol MEtab 1993;77:
A 5% weight loss can decrease FBG, insulin, A1C concentrations and medication requirements. Wing RR et al. Arch Intern Med 1987;147:

17. Setting Weight Management Goals
Many severely overweight persons have unrealistic expectations in setting weight loss goals (Blackburn, 1998)
Even modest weight loss may produce significant improvements in health
For some persons (especially those with BMI of ) weight maintenance may be a goal

18. Evaluation of Body Wt
R.1.1 Body mass index (BMI) and waist circumference should be used to classify overweight and obesity, estimate risk for disease, and to identify treatment options.
BMI and waist circumference are highly correlated to obesity or fat mass and risk of other diseases (NHLBI report). Fair, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

19. Estimation of Energy Needs
R.5.0 Estimated energy needs should be based on RMR. If possible, RMR should be measured (e.g., indirect calorimetry).
If RMR cannot be measured, then the Mifflin-St. Jeor equation using actual weight is the most accurate for estimating RMR for overweight and obese individuals. Strong, Conditional
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

20. Readiness to Change: A Brief Assessment
Has the individual sought weight loss on his/her own initiative?
What has led the patient to seek weight loss now?
What are the patient’s stress level and mood?
Does the individual have an eating disorder?

21. Readiness to Change: A Brief Assessment
Does the individual understand the requirements of treatment and believe that he/she can fulfill them?
How much weight does the patient expect to lose?

22. NIH Recommended Interventions
Dietary therapy
Physical activity
Behavior therapy
Pharmacotherapy
Bariatric surgery

23. Comprehensive Wt Mgt Program
R.2.0 Weight loss and weight maintenance therapy should be based on a comprehensive weight management program including diet, physical activity, and behavior therapy. The combination therapy is more successful than using any one intervention alone. Strong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

24. Dietary Interventions

25. Optimal Length of Wt Mgt Therapy
R.3.0. Medical Nutrition Therapy for weight loss should last at least 6 months or until weight loss goals are achieved, with implementation of a weight maintenance program after that time.
Greater frequency of contacts between the patient and practitioner may lead to more successful weight loss and maintenance. Strong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

26. Goals of Weight Management (NIH)
Achievement of healthy body weight (or close to desired BMI)
Select a realistic goal—no more than 1 to 1.5 lb/week
Prevent loss of LBM, especially from heart and brain
Support psychosocial factors

27. Reduced Calorie Diets
R.6.0 An individualized reduced calorie diet is the basis of the dietary component of a comprehensive weight management program.
Reducing dietary fat and/or carbohydrates is a practical way to create a caloric deficit of 500 – 1000 kcals below estimated energy needs and should result in a weight loss of 1 – 2 lbs per week. Strong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

28. Balanced Energy-Restricted Diet
Is the most widely-prescribed method of weight reduction
Should be nutritionally adequate except for energy
Energy level varies with individual’s size, sex, and activity, ranging from 800 kcals to 1500 kcals (NIH, 1998)

29. Balanced Energy-Restricted Diet
Should be relatively high in carbohydrate (50-55% of total kcals)
CHO sources should be fruits, vegetables, whole grains
Include generous protein (15-25% of kcals) for increased satiety and to assure adequate supply
Fat < 30% of kcals
Increased fiber to improve satiety (NIH, 1998)

30. Balanced Energy-Restricted Diet
Alcohol and high-sugar foods should be limited to limit excess energy
Use of non-nutritive sweeteners and fat replacements may improve the palatability of the diet
Vitamins and mineral supplements may be needed in programs that provide <1200 kcals for women or 1800 kcals for men (NIH, 1998)

31. Exchange System Diets
Allow flexibility in making food choices while limiting total caloric intake
Provides framework for healthy balance of nutrients
May be too complex or restrictive for some clients

32. Nutrition Education
R.10.0 Nutrition education should be individualized and included as part of the diet component of a comprehensive weight management program.
Short term studies show that nutrition education (e.g. reading nutrition labels, recipe modification, cooking classes) increases knowledge and may lead to improved food choices. Fair, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

33. Eating Frequency and Patterns
R.7.0 Total caloric intake should be distributed throughout the day, with the consumption of 4 to 5 meals/snacks per day including breakfast.
Consumption of greater energy intake during the day may be preferable to evening consumption. Fair, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

34. Portion Control
R.8.0 Portion control should be included as part of a comprehensive weight management program. Portion control at meals and snacks results in reduced energy intake and weight loss. Fair, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

35. Meal Replacements
R.9.0 For people who have difficulty with self selection and/or portion control, meal replacements (e.g., liquid meals, meal bars, calorie-controlled packaged meals) may be used as part of the diet component of a comprehensive weight management program.
Substituting one or two daily meals or snacks with meal replacements is a successful weight loss and weight maintenance strategy. Strong, Conditional
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

36. Low Glycemic Index Diets
R.11a A low glycemic index diet is not recommended for weight loss or weight maintenance as part of a comprehensive weight management program, since it has not been shown to be effective in these areas. Strong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

37. Lowfat Dairy Foods
R.11b. In order to meet current nutritional recommendations, incorporate 3-4 servings of low fat dairy foods a day as part of the diet component of a comprehensive weight management program.
Research suggests that calcium intake lower than recommended levels is associated with increased body weight. However, the effect of dairy and/or calcium at or above recommended levels on weight management is unclear. Fair, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

38. Low Carbohydrate Diets
R.11c Having patients focus on reducing carbohydrates rather than reducing calories and/or fat may be a short term strategy for some individuals.
Research indicates that focusing on reducing carbohydrate intake (<35% of kcals from carbohydrates) results in reduced energy intake.
Consumption of a low-carbohydrate diet is associated with a greater weight and fat loss than traditional reduced calorie diets during the first 6 months, but these differences are not significant after 1 year. Fair, Conditional
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

39. Very Low Calorie Diets (VLCD)
Diets providing kcals/day
Hypocaloric but relatively rich in protein ( g/kg/day)
Designed to include adequate vitamins, minerals, electrolytes, and EFAs
Completely replace usual meal intake
Usually given for weeks
Usually reserved for those with BMI>30; or with risk factors
NHLBI, 2000

40. Protein Sparing Modified Fast (PSMF)
Uses real food
Contains 1.5 g protein/kg IBW as lean meat, fish and poultry
May include low-carbohydrate vegetables
Only fat is that present in the protein sources
NIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000

41. Commercial VLCD Liquid Diets
Contain g of protein, g CHO, small amount of fat
Provides kcals
Patients lose 20 kg in 12 to 16 weeks
NIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000

42. VLCDs Cardiac complications a concern
Risks include potassium loss as well as body protein (higher in the less obese)
Requires close medical supervision and monitoring of serum electrolytes
But VLCDs may be a more
effective method of weight
loss for some
(Anderson et al Am J Clin Nutr 74;579:2001)

43. Dietary Therapy: NIH Guidelines
Very low calorie diets (VLCDs) should not be used routinely for weight loss therapy because they require special monitoring and supplementation
LCDs may be just as effective
NIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000

44. Behavioral Therapy in Weight Management

45. Behavioral Therapy: NIH Guidelines
Self-monitoring
Stress management
Stimulus control
Problem-solving
Contingency management
Cognitive restructuring
Social support

46. Behavior Therapy in Wt Mgt
R.13.0 A comprehensive weight management program should make maximum use of multiple strategies for behavior therapy (e.g. self monitoring, stress management, stimulus control, problem solving, contingency management, cognitive restructuring, and social support).
Behavior therapy in addition to diet and physical activity leads to additional weight loss. Continued behavioral interventions may be necessary to prevent a return to baseline weight. Strong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

47. Self Monitoring Records of place and time of food intake
Accompanying thoughts and feelings
Helps identify the physical and emotional settings in which eating occurs
Provides feedback on progress and puts responsibility on the patient

48. Problem Solving Process for defining the eating or weight problem
Generating possible solutions; evaluating the solutions, choosing the best one
Trialing the new behavior, evaluating outcome and generating alternatives

49. Stimulus Control Modification of
The settings or the chain of events that precede eating
The kinds of foods consumed
The consequences of eating
Become mindful of satiety cues
Put fork down between bites
Pausing during meals

50. Cognitive Restructuring
Teaches patients to identify, challenge, and correct negative thoughts
Positive self-talk

51. Behavior Modification
Most effective in mildly obese (20-40% overweight)
Patients can maintain losses of pounds
Longer programs more successful
Many patients regain the weight they lost over time
NIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000

52. Weight Loss Medications

53. Pharmacological Therapy NIH Guidelines
Should be used only in the context of a program that includes lifestyle changes
If lifestyle changes do not promote weight loss after 6 months, drugs should be considered
Limited to those with BMI ≥30; or ≥27 with risk factors
NIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000

54. Wt Loss Medications
R.14.0 FDA-approved weight loss medications may be part of a comprehensive weight management program.
Dietitians should collaborate with other members of the health care team regarding the use of FDA-approved weight loss medications for people who meet the NHLBI criteria.
Research indicates that pharmacotherapy may enhance weight loss in some overweight and obese adults. Strong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

55. Catecholaminergic Drugs
Appetite suppressants
Act on the brain, increasing the availability of norepinephrine
Schedule II anorexic agents
High potential for abuse
Include amphetamine, phenmetrazine HCl
Not recommended for weight management
Schedule III agents
Some potential for abuse
Include benzphetamine HCl, phendimetrazine tartrate
See Table 21-5 Krause 12th edition, p. 551

56. Catecholaminergic Drugs
Schedule IV agents
Includes diethypropion HCl, manzindol HCl, phentermine HCl, phentermine resin
Low potential for abuse
Can raise blood pressure, so prescribed with caution in patients with hypertension
NIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000

57. Serotonin Reuptake Inhibitors
Includes sibutramine (Meridia)
Inhibits the reuptake of serotonin and norepinephrine
Initially developed to treat depression
Use caution in hypertension, CHD, arrhythmias, CHF
NIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000

58. Orlistat (Xenical) Lipase inhibitor
Acts directly on the gastrointestinal tract to inhibit fat absorption
Associated with reduced LDL-C and increased HDL; improved glycemic control, reduced blood pressure
Some concern about fat soluble vitamins
Side effects: oily spotting, fecal urgency, flatus with discharge
NIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000

59. FDA Approves Reduced Dose of Orlistat for Over the Counter
Over the counter dose of orlistat, a lipase inhibitor
Half the dose of prescription form (Xenical)
The only FDA-approved over the counter wt mgt drug
Available summer 2007

60. Serotoninergic Agents
Increase serotonin levels in the brain
Fenfluramine hydrochloride and dexfenfluramine HCl (Fen-Phen) were removed from the market in 1997 due to association with heart valve disease and pulmonary hypertension

61. Pharmacological Obesity Treatments
Weight loss of about 1 lb/week can be expected
Most weight loss will occur within the first 6 months of therapy
Significant weight maintenance as long as the drug treatment is continued
Most patients regain weight if medication is stopped

62. Pharmacological Obesity Treatments
Weight-loss medications lead to an additional weight loss of 5 to 22 pounds more than with non-drug obesity treatments
Two to 20 kg total loss, usually during first 6 months of treatment
When drugs are discontinued, weight regain occurs

63. Physical Activity and Weight Management

64. Physical Activity
R.12.0 Physical activity should be part of a comprehensive weight management program. Physical activity level should be assessed and individualized long-term goals established to accumulate at least 30 minutes or more of moderate intensity physical activity on most, and preferably, all days of the week, unless medically contraindicated.
Physical activity contributes to weight loss, may decrease abdominal fat, and may help with maintenance of weight loss. Strong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

65. Physical Activity: NIH Guidelines
Physical activity increases energy expenditure and plays an integral role in weight maintenance
Reduces the risk of heart disease more than weight loss alone
Reduces body fat, prevents decrease in muscle mass during weight loss
All adults: goal of 30 minutes or more of moderate-intensity physical activity on most and preferably all days.
NIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000

66. Role of Physical Activity in Weight Management
Physical activity usually will not lead to a greater weight loss over diet alone in a 6-month period (NIH, 2000)
Physical activity is most helpful in preventing weight regain
Physical activity also is beneficial in reducing risk for heart disease and diabetes beyond the effect of weight loss

67. Role of Physical Activity in Weight Management
Exercise helps balance the loss of LBM and reduction in RMR caused by hypocaloric diets
A combination of aerobic exercise and resistance training is recommended
Even when weight loss does not occur, loss of body fat often does
May require 2 months to see loss of weight through exercise

68. U.S. Dietary Guidelines 2005
Suggest 60 minutes of moderate-vigorous activity on most days of the week to prevent weight gain in adulthood
To sustain weight loss in adulthood: at least minutes of daily moderate-intensity physical activity
Achieve physical fitness by including cardiovascular conditioning, stretching exercises for flexibility, and resistance exercises or calisthenics for muscle strength and endurance.

69. Role of Physical Activity in Weight Management
Other Benefits:
—Improved sense of well-being
—Relief of boredom
—Sense of control
—Relief from depression

70. Bariatric Surgery
R Dietitians should collaborate with other members of the health care team regarding the appropriateness of bariatric surgery for people who have not achieved weight loss goals with less invasive weight loss methods and who meet the NHLBI criteria.
Separate ADA evidence based guidelines are being developed on nutrition care in bariatric surgery. Strong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

71. Bariatric Surgery: NIH Guidelines
Option for well-informed and motivated patients with clinically severe obesity (BMI≥40 or BMI ≥35 with serious co-morbid conditions
NIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000

72. Candidates for Bariatric Surgery
BMI of 40 or more—about 100 pounds overweight for men and 80 pounds for women
BMI between 35 and 39.9 and a serious obesity-related health problem such as type 2 diabetes, heart disease, or severe sleep apnea
Willingness to make associated lifestyle changes

73. Bariatric Surgery Options
Restrictive
Malabsorptive
Combination restrictive/malabsorptive

74. Restrictive Procedures
Adjustable gastric banding (AGB) a hollow band made of silicone rubber is placed around the stomach near its upper end, creating a small pouch and a narrow passage into the rest of the stomach
Vertical banded gastroplasty. VBG uses both a band and staples to create a small stomach pouch (not often used today)

75. Restrictive Surgery: Adjustable Gastric Band

76. Diet After Surgery
After restrictive surgeries, patients can only eat ½ cup to 1 cup of food at a time
Foods often must be soft and chewed thoroughly
Patients who eat too fast or the wrong kinds of food may have vomiting

77. Restrictive Procedures: Advantages
Don’t interfere with the normal digestive process
Easier to perform and generally safer than malabsorptive surgeries
AGB often done laparoscopically
Can be reversed if necessary

78. Restrictive Procedures: Disadvantages
Generally results in less weight loss
Patients generally lose about half of their excess body weight in the first year after restrictive procedures
Only 20% keep weight off over 10 years, though there is evidence that AGB is more effective than VBG

79. Restrictive/Malabsorptive Procedures
Roux-en-Y gastric bypass (RGB) is the most common
The surgeon creates a small stomach pouch to restrict food intake. Next, a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum and the first portion of the jejunum.
This reduces the amount of calories and nutrients the body absorbs.

80. Restrictive/Malabsorptive: Roux en Y

81. Restrictive/Malabsorptive Procedures: Advantages
Patients lose weight quickly and continue to lose months after the procedure
With RGB, many patients maintain a weight loss of 60 to 70 percent of their excess weight for 10 years or more

82. Restrictive/Malabsorptive Procedures: Disadvantages
More difficult to perform
More likely to result in long-term nutritional deficiencies (calcium, iron)
Greater risk of dumping syndrome
Increased likelihood of complications including hernia (decreased with laparoscopic procedures)

83. Weight Management—Children
Goals: Weight maintenance or slowing of gains
Grow into weight
If severely obese, lose no more than 1 lb monthly to reach desired adult weight for height

84. Weight Management in Children
At risk at BMI 85% to 95%ile; obese at 95%
Review parents’ history—height, weight, etc.
Weight management in children is a family affair

85. Weight Management in Children
Overweight children should try to achieve weight maintenance or slowing of the rate of weight gain, not weight loss
Depends on age and degree of overweight
Once adult height is achieved, weight loss is necessary to improve health

86. Summary
Even modest weight loss can produce improvements in overall health in persons who are overweight (lipids, BG, insulin, blood pressure)
Most persons will need sustained, long-term lifestyle interventions to achieve significant weight loss