2. Treatment Options of Obesity 1. Lifestyle 2. Medical 3. Surgical

3. Lifestyle Treatments for Weight Loss  Successful weight loss and maintenance requires a three-pronged approach: 1. Changing behavior patterns 2. Making dietary adjustments 3. Increasing physical activity

4. Changing Behavior Patterns Behavior Modification – an ability to alter lifelong attitudes toward diet and exercise may one of the greatest, but most important, challenges Behavior Modification – an ability to alter lifelong attitudes toward diet and exercise may one of the greatest, but most important, challenges Important to set : Important to set : 1. Realistic goals 2. Seek support 3. Make changes gradually 4. Become aware of “unhelpful” behaviors 5. Evaluate “triggers” and relationship with food 6. Practice, practice, practice

5. Making Dietary Adjustments Diet - derived from the Greek word “diaita”, which means “way of living”. Diet - derived from the Greek word “diaita”, which means “way of living”. 1. Realistic energy level – at least 1. Realistic energy level – at least 10 kcals/lb./day 10 kcals/lb./day 2. Choose foods with low energy density 2. Choose foods with low energy density 3. Cut down on sugar added to foods - sugar 3. Cut down on sugar added to foods - sugar is the #1 food additive in the U.S. is the #1 food additive in the U.S. accounting for 16% of all calories. accounting for 16% of all calories. 4. Practice portion control – “super-sizing”. 4. Practice portion control – “super-sizing”. 5. Consider the calories in beverages 5. Consider the calories in beverages

6. Energy Density By selecting the low-fat version, a person can enjoy the same amount of tuna for fewer calories. Copyright 2005 Wadsworth Group, a division of Thomson Learning

7. Increasing Physical Activity Physical activity – crucial to success! Physical activity – crucial to success!Why? 1. Burns energy 2. Speeds metabolism 3. Helps control appetite 4. Reduces stress; improves self-esteem What & How Much? 1. Essential activity is enjoyed & suits lifestyle 2. Aerobic exercise encouraged but strengthening & flexibility important too strengthening & flexibility important too Think FIT – F=frequency, I=intensity, T=time

8. Physical Activity –Activity and energy expenditure –Activity and metabolism –Activity and body composition –Activity and appetite control –Activity and psychological benefits –Choosing activities –Spot reducing Copyright 2005 Wadsworth Group, a division of Thomson Learning

9. Medical Treatments for Obesity  More aggressive strategies for those with high medical risks &/or severe obesity 1. Very-Low-Calorie (<800 kcals/day) and Low-Calorie diets – must include protein & Low-Calorie diets – must include protein & vitamin/mineral supplements to preserve vitamin/mineral supplements to preserve muscle mass and prevent nutritional muscle mass and prevent nutritional deficiencies; require close medical deficiencies; require close medical supervision, behavioral counseling, and supervision, behavioral counseling, and instruction for changing eating pattern instruction for changing eating pattern once food is reintroduced once food is reintroduced

10. 2. Medications – drug therapy helps suppress appetite, increase satiety, block the digestion appetite, increase satiety, block the digestion and absorption of dietary fat, or alter the and absorption of dietary fat, or alter the body’s energy balance; anorectics do not body’s energy balance; anorectics do not magically “melt away” pounds but do make magically “melt away” pounds but do make it easier to adhere to lifestyle changes and it easier to adhere to lifestyle changes and provide the opportunity to alter behaviors; provide the opportunity to alter behaviors; not without risk & may be needed long-term not without risk & may be needed long-term 3. Herbal supplements – popular but surprisingly little reliable information about surprisingly little reliable information about their safety and effectiveness their safety and effectiveness

11. Surgical Treatments for Obesity  Bariatric surgery has been recognized by the NIH as an accepted and effective approach that provides consistent, permanent weight loss for clinically severe obese people or for obese people with significant complications of obesity.  Traditional nonsurgical treatment options, lifestyle and medical, are often not effective long term for obese people long term for obese people  Improves and – in some cases - resolves co- morbidities Weigh benefits of surgery vs. the risks of staying morbidly obese Weigh benefits of surgery vs. the risks of staying morbidly obese

12. % Medical Co-Morbidities Resolved after Bariatric Surgery Wittgrove AC, Clark GW. Laparoscopic Gastric Bypass roux-n-y-500 patients. Obes Surg 2000. And others.

13. Surgical Procedures Purely restrictive procedures – normal digestion & absorption but create the feeling of fullness  Vertical Banded Gastroplasty – the upper stomach is stapled vertically creating a small pouch separated from the rest of the stomach by a band or ring restricting the flow of food pouch separated from the rest of the stomach by a band or ring restricting the flow of food  Laparoscopic Adjustable Gastric Banding – an adjustable silicone band divides the stomach into one small & one large portion

14. Combination restrictive & malabsorptive procedure  Gastric Bypass Roux-en-Y– considered the “gold standard” - a small upper gastric pouch is completed separated from the rest of the stomach and a segment of the small intestine is rerouted to connect directly to the gastric pouch

15. Surgical Procedures Copyright 2005 Wadsworth Group, a division of Thomson Learning

16. How Does the Surgeries Work? Surgery factors: restriction of meal size restriction of meal size “dumping syndrome” “dumping syndrome” some malabsorption some malabsorption decreased appetite decreased appetite  There are side effects and risks with all three procedures life-long medical care is required.

17. Patient Selection Criteria for Bariatric Surgery Surgery indicated in patients with: BMI of 40 or over BMI of 40 or over BMI of 35 or higher with significant co- morbidity BMI of 35 or higher with significant co- morbidity Long-standing history of obesity Long-standing history of obesity Multiple unsuccessful attempts to lose weight using nonsurgical methods Multiple unsuccessful attempts to lose weight using nonsurgical methods Ability to comply with dietary and behavioral changes as recommended by the weight management team Ability to comply with dietary and behavioral changes as recommended by the weight management team

18. Who Is a Surgical Candidate? Meets NIH criteria Meets NIH criteria No endocrine cause of obesity No endocrine cause of obesity Acceptable operative risk Acceptable operative risk Understands surgery and risks Understands surgery and risks Absence of drug or alcohol problem Absence of drug or alcohol problem No uncontrolled psychological conditions No uncontrolled psychological conditions Consensus after multidisciplinary team evaluation: Consensus after multidisciplinary team evaluation: Primary care clinician, bariatrician, surgeon, psychologist, dietitian, exercise physiologist Primary care clinician, bariatrician, surgeon, psychologist, dietitian, exercise physiologist Well-informed, motivated, and dedicated to life- style change and long-term follow-up Well-informed, motivated, and dedicated to life- style change and long-term follow-up

19.  All three treatment options require a three-pronged approach for successful weight loss and maintenance : 1. Changing behavior patterns 2. Making dietary adjustments 3. Increasing physical activity

20. Conclusion In theory, weight control is a simple matter of balancing energy intake (the calories supplied by food) with energy output (the calories expended by physical activity and metabolism). In theory, weight control is a simple matter of balancing energy intake (the calories supplied by food) with energy output (the calories expended by physical activity and metabolism). In practice, the task is clearly not that simple!! In practice, the task is clearly not that simple!! While the basic principle of energy balance remains true, genetics, metabolism, and environment are important mechanisms controlling how much a person eats and how their body uses and stores energy. While the basic principle of energy balance remains true, genetics, metabolism, and environment are important mechanisms controlling how much a person eats and how their body uses and stores energy.