weight management medical and nutritional therapy

Weight Management Weight Management Strategies: Medical and Strategies: Medical and Nutritional TherapyNutritional Therapy

What is Successful What is Successful Weight Loss?Weight Loss? Common definition: Lose at least Common definition: Lose at least

10% of starting weight and keep 10% of starting weight and keep it off at least one year. it off at least one year.

What is the Goal of What is the Goal of Obesity Treatment?Obesity Treatment? Specifically, the goal of obesity Specifically, the goal of obesity

treatment should be refocused treatment should be refocused from weight loss alone, which is from weight loss alone, which is often aimed at appearance, to often aimed at appearance, to weight management, achieving weight management, achieving the best weight possible in the the best weight possible in the context of overall health.context of overall health. – –FTC FTC PanelPanel, , Commercial Weight Loss Products Commercial Weight Loss Products and Programsand ProgramsWhat Consumers Stand To Gain and What Consumers Stand To Gain and Lose, Lose, 19971997

http://www.ftc.gov/os/1998/03/weightlo.rpt.htm accessed 3-13-06

Who Should Consider A Who Should Consider A Weight Management Weight Management Intervention?Intervention? Persons with a BMI of >30Persons with a BMI of >30 Persons with a BMI between 25-Persons with a BMI between 25-

29.9 OR a high-risk waist 29.9 OR a high-risk waist circumference, and two or more circumference, and two or more risk factorsrisk factors

Persons who are ready to changePersons who are ready to change

NHLBI Obesity Education Initiative. The Practical Guide Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI 00-4084, 2000.

Obesity-Associated Risk Obesity-Associated Risk Factors: High Absolute Factors: High Absolute RiskRisk Established coronary heart Established coronary heart

diseasedisease Other atherosclerotic diseasesOther atherosclerotic diseases Type 2 diabetesType 2 diabetes Sleep apneaSleep apnea

NHLBI Obesity Education Initiative. The Practical Guide Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI 00-4084, 2000.

Obesity-Associated Risk Obesity-Associated Risk Factors: 3 or More = Factors: 3 or More = ↑↑ RiskRisk HypertensionHypertension Cigarette smokingCigarette smoking High low-density lipoprotein cholesterolHigh low-density lipoprotein cholesterol Low high-density lipoprotein cholesterolLow high-density lipoprotein cholesterol Impaired fasting glucoseImpaired fasting glucose Family history of early cardiovascular Family history of early cardiovascular

diseasedisease Age (male Age (male ≥ 45 years, female ≥ 55 ≥ 45 years, female ≥ 55

years)years)NHLBI Obesity Education Initiative. The Practical Guide Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI

00-4084, 2000.

Other Obesity-Other Obesity-Associated Risk Associated Risk FactorsFactors OsteoarthritisOsteoarthritis GallstonesGallstones Stress incontinenceStress incontinence Gynecological abnormalitiesGynecological abnormalities

NHLBI Obesity Education Initiative. The Practical Guide to Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI 00-4084, 2000.

How Much and How How Much and How Fast?Fast? NIH guidelines recommend a weight NIH guidelines recommend a weight

loss of .5 to 1 pound/week for persons loss of .5 to 1 pound/week for persons with a BMI of 27-35 and 1-2 pounds a with a BMI of 27-35 and 1-2 pounds a week for those with a BMI>35 kg/m2week for those with a BMI>35 kg/m2

Allow 6 months to achieve 10% weight Allow 6 months to achieve 10% weight lossloss

After 6 months, focus should shift to After 6 months, focus should shift to weight maintenance for 6 monthsweight maintenance for 6 months

Following this, weight loss efforts may Following this, weight loss efforts may resume (NIH, 1998)resume (NIH, 1998)

Weight Loss GoalsWeight Loss Goals

R.4.0. Individualized goals of weight R.4.0. Individualized goals of weight loss therapy should be to reduce body loss therapy should be to reduce body weight at an optimal rate of 1-2 lbs per weight at an optimal rate of 1-2 lbs per week for the first 6 months and to week for the first 6 months and to achieve an initial weight loss goal of achieve an initial weight loss goal of up to 10% from baseline. up to 10% from baseline.

These goals are realistic, achievable, These goals are realistic, achievable, and sustainable. and sustainable. Strong, ImperativeStrong, Imperative

American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

Rates of Weight Loss Rates of Weight Loss VaryVary Men will lose weight faster than Men will lose weight faster than

women of similar size, due to women of similar size, due to higher LBM and RMRhigher LBM and RMR

A heavier person (who has higher A heavier person (who has higher energy needs) will lose weight energy needs) will lose weight faster than a smaller person on faster than a smaller person on the same caloric regimenthe same caloric regimen

Modest Weight Loss and Modest Weight Loss and Health: Diabetes Health: Diabetes PreventionPrevention A 7% weight loss (mean 15 pounds) A 7% weight loss (mean 15 pounds)

through diet and exercise in high risk through diet and exercise in high risk individuals was associated with a 58% individuals was associated with a 58% reduction of diabetes incidence in the reduction of diabetes incidence in the Diabetes Prevention Program Diabetes Prevention Program DPP Research DPP Research Group. N Engl J Med. 2002 Feb 7;346(6):393-403. Group. N Engl J Med. 2002 Feb 7;346(6):393-403.

An average 7.7 pound weight loss was An average 7.7 pound weight loss was associated with a 58% reduction in associated with a 58% reduction in diabetes incidence in high risk diabetes incidence in high risk individuals in the Finnish Diabetes individuals in the Finnish Diabetes Prevention study. Prevention study. FDPS GroupFDPS Group. . N Engl J MedN Engl J Med 344:1343–1350, 2001 344:1343–1350, 2001

Modest Weight Loss Modest Weight Loss and Health: and Health: HypertensionHypertension Weight loss of as little as 4.5 kg (10 Weight loss of as little as 4.5 kg (10

pounds) will improve or prevent pounds) will improve or prevent hypertension in a large segment of hypertension in a large segment of overweight persons. overweight persons. Seventh Report of the Seventh Report of the Joint National Committee on Prevention, Detection, Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC Evaluation, and Treatment of High Blood Pressure (JNC 7) 7) http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7fhttp://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdfull.pdf

Clinically significant long-term Clinically significant long-term reductions in blood pressure and reductions in blood pressure and reduced risk for hypertension can be reduced risk for hypertension can be achieved with modest weight loss and achieved with modest weight loss and increased physical activity. increased physical activity. American Dietetic American Dietetic Association Evidence Analysis Library, Hypertension and Association Evidence Analysis Library, Hypertension and hyperlipidemia. http://www.adaevidencelibrary.org/hyperlipidemia. http://www.adaevidencelibrary.org/

Modest Weight Loss Modest Weight Loss and Health: and Health: HyperlipidemiaHyperlipidemia The ATP-III guidelines recommend a The ATP-III guidelines recommend a

10% weight loss in overweight persons 10% weight loss in overweight persons with hyperlipidemia. with hyperlipidemia. http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdfhttp://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf

A weight loss of A weight loss of ≥2.25 kg was ≥2.25 kg was associated with a 40-50% reduction in associated with a 40-50% reduction in cardiovascular risk factors in the cardiovascular risk factors in the Framingham Offspring Study (BP, Framingham Offspring Study (BP, triglyceride, TC, FBS, HDL) triglyceride, TC, FBS, HDL) Karason K et al. Int J Karason K et al. Int J

Obes Relat Metab Disord 1999;23:948-56Obes Relat Metab Disord 1999;23:948-56..

Modest Weight Loss Modest Weight Loss and Health: Diabetesand Health: Diabetes Calorie restriction and weight loss Calorie restriction and weight loss

improves insulin sensitivity and improves insulin sensitivity and glycemic control in obese patients with glycemic control in obese patients with Type 2 diabetes. Type 2 diabetes. Henry RR et al. J Clin Endocrinol Henry RR et al. J Clin Endocrinol Metab 1985;61:917-25; Kelly DE et al. J Clin Endocrinol Metab 1985;61:917-25; Kelly DE et al. J Clin Endocrinol MEtab 1993;77:1287-93. MEtab 1993;77:1287-93.

A 5% weight loss can decrease FBG, A 5% weight loss can decrease FBG, insulin, A1C concentrations and insulin, A1C concentrations and medication requirements. medication requirements. Wing RR et al. Arch Wing RR et al. Arch

Intern Med 1987;147:1749-53Intern Med 1987;147:1749-53..

Setting Weight Setting Weight Management GoalsManagement Goals Many severely overweight persons Many severely overweight persons

have unrealistic expectations in have unrealistic expectations in setting weight loss goals (Blackburn, setting weight loss goals (Blackburn, 1998)1998)

Even modest weight loss may Even modest weight loss may produce significant improvements in produce significant improvements in healthhealth

For some persons (especially those For some persons (especially those with BMI of 25-29.9) weight with BMI of 25-29.9) weight maintenance may be a goalmaintenance may be a goal

Evaluation of Body WtEvaluation of Body Wt

R.1.1 Body mass index (BMI) and waist R.1.1 Body mass index (BMI) and waist circumference should be used to circumference should be used to classify overweight and obesity, classify overweight and obesity, estimate risk for disease, and to estimate risk for disease, and to identify treatment options. identify treatment options.

BMI and waist circumference are BMI and waist circumference are highly correlated to obesity or fat mass highly correlated to obesity or fat mass and risk of other diseases (NHLBI and risk of other diseases (NHLBI report). report). Fair,Fair, ImperativeImperative


Estimation of Energy Estimation of Energy NeedsNeeds R.5.0 Estimated energy needs should be R.5.0 Estimated energy needs should be

based on RMR. If possible, RMR should based on RMR. If possible, RMR should be measured (e.g., indirect calorimetry). be measured (e.g., indirect calorimetry).

If RMR cannot be measured, then the If RMR cannot be measured, then the Mifflin-St. Jeor equation using Mifflin-St. Jeor equation using actualactual weight is the most accurate for weight is the most accurate for estimating RMR for overweight and estimating RMR for overweight and obese individuals. obese individuals. Strong, ConditionalStrong, Conditional


Readiness to Change: Readiness to Change: A Brief AssessmentA Brief Assessment Has the individual sought weight Has the individual sought weight

loss on his/her own initiative?loss on his/her own initiative? What has led the patient to seek What has led the patient to seek

weight loss now?weight loss now? What are the patient’s stress What are the patient’s stress

level and mood? level and mood? Does the individual have an Does the individual have an

eating disorder?eating disorder?

Readiness to Change: Readiness to Change: A Brief AssessmentA Brief Assessment Does the individual understand Does the individual understand

the requirements of treatment the requirements of treatment and believe that he/she can fulfill and believe that he/she can fulfill them?them?

How much weight does the How much weight does the patient expect to lose? patient expect to lose?

NIH Recommended NIH Recommended InterventionsInterventions Dietary therapyDietary therapy Physical activityPhysical activity Behavior therapyBehavior therapy PharmacotherapyPharmacotherapy Bariatric surgeryBariatric surgery

Comprehensive Wt Comprehensive Wt Mgt ProgramMgt Program R.2.0 Weight loss and weight R.2.0 Weight loss and weight

maintenance therapy should be maintenance therapy should be based on a comprehensive weight based on a comprehensive weight management program including management program including diet, physical activity, and behavior diet, physical activity, and behavior therapy. The combination therapy therapy. The combination therapy is more successful than using any is more successful than using any one intervention alone. one intervention alone. Strong, Strong, ImperativeImperative


Dietary InterventionsDietary Interventions

Optimal Length of Wt Optimal Length of Wt Mgt TherapyMgt Therapy R.3.0. Medical Nutrition Therapy for R.3.0. Medical Nutrition Therapy for

weight loss should last at least 6 months weight loss should last at least 6 months or until weight loss goals are achieved, or until weight loss goals are achieved, with implementation of a weight with implementation of a weight maintenance program after that time. maintenance program after that time.

Greater frequency of contacts between Greater frequency of contacts between the patient and practitioner may lead to the patient and practitioner may lead to more successful weight loss and more successful weight loss and maintenance. maintenance. Strong, ImperativeStrong, Imperative


Goals of Weight Goals of Weight Management (NIH)Management (NIH)

Achievement of healthy body weight Achievement of healthy body weight (or close to desired BMI)(or close to desired BMI)

Select a realistic goal—no more than Select a realistic goal—no more than 1 to 1.5 lb/week1 to 1.5 lb/week

Prevent loss of LBM, especially from Prevent loss of LBM, especially from heart and brainheart and brain

Support psychosocial factorsSupport psychosocial factors

Reduced Calorie Reduced Calorie DietsDiets R.6.0 An individualized reduced calorie R.6.0 An individualized reduced calorie

diet is the basis of the dietary diet is the basis of the dietary component of a comprehensive weight component of a comprehensive weight management program. management program.

Reducing dietary fat and/or Reducing dietary fat and/or carbohydrates is a practical way to carbohydrates is a practical way to create a caloric deficit of 500 – 1000 create a caloric deficit of 500 – 1000 kcals below estimated energy needs and kcals below estimated energy needs and should result in a weight loss of 1 – 2 lbs should result in a weight loss of 1 – 2 lbs per week. per week. Strong, ImperativeStrong, ImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

Balanced Energy-Balanced Energy-Restricted DietRestricted Diet Is the most widely-prescribed Is the most widely-prescribed

method of weight reductionmethod of weight reduction Should be nutritionally adequate Should be nutritionally adequate

except for energyexcept for energy Energy level varies with Energy level varies with

individual’s size, sex, and activity, individual’s size, sex, and activity, ranging from 800 kcals to 1500 ranging from 800 kcals to 1500 kcals (NIH, 1998)kcals (NIH, 1998)

Balanced Energy-Balanced Energy-Restricted DietRestricted Diet Should be relatively high in Should be relatively high in

carbohydrate (50-55% of total kcals)carbohydrate (50-55% of total kcals)– CHO sources should be fruits, vegetables, CHO sources should be fruits, vegetables,

whole grainswhole grains Include generous protein (15-25% of Include generous protein (15-25% of

kcals) for increased satiety and to kcals) for increased satiety and to assure adequate supplyassure adequate supply

Fat < 30% of kcalsFat < 30% of kcals Increased fiber to improve satiety Increased fiber to improve satiety

(NIH, 1998)(NIH, 1998)

Balanced Energy-Balanced Energy-Restricted DietRestricted Diet Alcohol and high-sugar foods Alcohol and high-sugar foods

should be limited to limit excess should be limited to limit excess energyenergy

Use of non-nutritive sweeteners Use of non-nutritive sweeteners and fat replacements may improve and fat replacements may improve the palatability of the dietthe palatability of the diet

Vitamins and mineral supplements Vitamins and mineral supplements may be needed in programs that may be needed in programs that provide <1200 kcals for women or provide <1200 kcals for women or 1800 kcals for men (NIH, 1998)1800 kcals for men (NIH, 1998)

Exchange System Exchange System DietsDiets Allow flexibility in making Allow flexibility in making

food choices while limiting food choices while limiting total caloric intaketotal caloric intake

Provides framework for Provides framework for healthy balance of healthy balance of nutrientsnutrients

May be too complex or May be too complex or restrictive for some restrictive for some clientsclients

Nutrition EducationNutrition Education

R.10.0 Nutrition education should be R.10.0 Nutrition education should be individualized and included as part of the individualized and included as part of the diet component of a comprehensive diet component of a comprehensive weight management program. weight management program.

Short term studies show that nutrition Short term studies show that nutrition education (e.g. reading nutrition labels, education (e.g. reading nutrition labels, recipe modification, cooking classes) recipe modification, cooking classes) increases knowledge and may lead to increases knowledge and may lead to improved food choices. improved food choices. Fair, Fair, ImperativeImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

Eating Frequency and Eating Frequency and PatternsPatterns R.7.0 Total caloric intake should be R.7.0 Total caloric intake should be

distributed throughout the day, with distributed throughout the day, with the consumption of 4 to 5 the consumption of 4 to 5 meals/snacks per day including meals/snacks per day including breakfast. breakfast.

Consumption of greater energy intake Consumption of greater energy intake during the day may be preferable to during the day may be preferable to evening consumption. evening consumption. Fair, Fair, ImperativeImperative


Portion ControlPortion Control

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

Meal ReplacementsMeal Replacements

R.9.0 For people who have difficulty with self R.9.0 For people who have difficulty with self selection and/or portion control, meal selection and/or portion control, meal replacements (e.g., liquid meals, meal bars, replacements (e.g., liquid meals, meal bars, calorie-controlled packaged meals) may be calorie-controlled packaged meals) may be used as part of the diet component of a used as part of the diet component of a comprehensive weight management comprehensive weight management program. program.

Substituting one or two daily meals or snacks Substituting one or two daily meals or snacks with meal replacements is a successful with meal replacements is a successful weight loss and weight maintenance weight loss and weight maintenance strategy. strategy. Strong, ConditionalStrong, Conditional


Low Glycemic Index Low Glycemic Index DietsDiets

R.11a A low glycemic index diet is R.11a A low glycemic index diet is notnot recommended for weight loss recommended for weight loss or weight maintenance as part of or weight maintenance as part of a comprehensive weight a comprehensive weight management program, since it management program, since it has not been shown to be has not been shown to be effective in these areas. effective in these areas. Strong, Strong, ImperativeImperative


Lowfat Dairy FoodsLowfat Dairy Foods

R.11b. In order to meet current nutritional R.11b. In order to meet current nutritional recommendations, incorporate 3-4 recommendations, incorporate 3-4 servings of low fat dairy foods a day as servings of low fat dairy foods a day as part of the diet component of a part of the diet component of a comprehensive weight management comprehensive weight management program. program.

Research suggests that calcium intake Research suggests that calcium intake lower than recommended levels is lower than recommended levels is associated with increased body weight. associated with increased body weight. However, the effect of dairy and/or However, the effect of dairy and/or calcium at or above recommended levels calcium at or above recommended levels on weight management is unclear. on weight management is unclear. Fair, Fair, ImperativeImperative


Low Carbohydrate Low Carbohydrate DietsDiets

R.11c Having patients focus on reducing R.11c Having patients focus on reducing carbohydrates rather than reducing calories carbohydrates rather than reducing calories and/or fat may be a short term strategy for and/or fat may be a short term strategy for some individuals. some individuals.

Research indicates that focusing on reducing Research indicates that focusing on reducing carbohydrate intake (<35% of kcals from carbohydrate intake (<35% of kcals from carbohydrates) results in reduced energy carbohydrates) results in reduced energy intake. intake.

Consumption of a low-carbohydrate diet is Consumption of a low-carbohydrate diet is associated with a greater weight and fat loss associated with a greater weight and fat loss than traditional reduced calorie diets during than traditional reduced calorie diets during the first 6 months, but these differences are the first 6 months, but these differences are not significant after 1 year. not significant after 1 year. Fair, ConditionalFair, Conditional


Very Low Calorie Diets Very Low Calorie Diets (VLCD)(VLCD) Diets providing 200-800 kcals/dayDiets providing 200-800 kcals/day Hypocaloric but relatively rich in protein Hypocaloric but relatively rich in protein

(.8-1.5 g/kg/day)(.8-1.5 g/kg/day) Designed to include adequate vitamins, Designed to include adequate vitamins,

minerals, electrolytes, and EFAsminerals, electrolytes, and EFAs Completely replace usual meal intakeCompletely replace usual meal intake Usually given for 12-16 weeksUsually given for 12-16 weeks Usually reserved for those with BMI>30; Usually reserved for those with BMI>30;

or 27-30 with risk factorsor 27-30 with risk factors

NHLBI, 2000

Protein Sparing Protein Sparing Modified Fast (PSMF)Modified Fast (PSMF) Uses real foodUses real food Contains 1.5 g protein/kg IBW as Contains 1.5 g protein/kg IBW as

lean meat, fish and poultrylean meat, fish and poultry May include low-carbohydrate May include low-carbohydrate

vegetablesvegetables Only fat is that present in the Only fat is that present in the

protein sourcesprotein sources

NIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000

Commercial VLCD Commercial VLCD Liquid DietsLiquid Diets Contain 33-70 g Contain 33-70 g

of protein, 30-45 of protein, 30-45 g CHO, small g CHO, small amount of fatamount of fat

Provides 400-800 Provides 400-800 kcalskcals

Patients lose 20 Patients lose 20 kg in 12 to 16 kg in 12 to 16 weeksweeksNIH NHLBI The practical guide.

Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000

VLCDsVLCDs

Cardiac complications a concernCardiac complications a concern Risks include potassium loss as well as Risks include potassium loss as well as

body protein (higher in the less obese)body protein (higher in the less obese) Requires close medical supervision Requires close medical supervision

and monitoring of serum electrolytesand monitoring of serum electrolytes But VLCDs may be a more But VLCDs may be a more effective method of weighteffective method of weight loss for someloss for some (Anderson et al Am J Clin Nutr 74;579:2001)(Anderson et al Am J Clin Nutr 74;579:2001)

Dietary Therapy: NIH Dietary Therapy: NIH GuidelinesGuidelines Very low calorie diets (VLCDs) Very low calorie diets (VLCDs)

should not be used routinely for should not be used routinely for weight loss therapy because they weight loss therapy because they require special monitoring and require special monitoring and supplementationsupplementation

LCDs may be just as effectiveLCDs may be just as effective


Behavioral Therapy Behavioral Therapy in Weight in Weight ManagementManagement

Behavioral Therapy: Behavioral Therapy: NIH GuidelinesNIH Guidelines Self-monitoringSelf-monitoring Stress managementStress management Stimulus controlStimulus control Problem-solvingProblem-solving Contingency managementContingency management Cognitive restructuringCognitive restructuring Social supportSocial support

Behavior Therapy in Behavior Therapy in Wt MgtWt Mgt R.13.0 A comprehensive weight management R.13.0 A comprehensive weight management

program should make maximum use of program should make maximum use of multiple strategies for behavior therapy (e.g. multiple strategies for behavior therapy (e.g. self monitoring, stress management, self monitoring, stress management, stimulus control, problem solving, stimulus control, problem solving, contingency management, cognitive contingency management, cognitive restructuring, and social support). restructuring, and social support).

Behavior therapy in addition to diet and Behavior therapy in addition to diet and physical activity leads to additional weight physical activity leads to additional weight loss. Continued behavioral interventions may loss. Continued behavioral interventions may be necessary to prevent a return to baseline be necessary to prevent a return to baseline weight. weight. Strong, ImperativeStrong, Imperative


Self MonitoringSelf Monitoring

Records of place and time of food Records of place and time of food intakeintake

Accompanying thoughts and feelingsAccompanying thoughts and feelings Helps identify the physical and Helps identify the physical and

emotional settings in which eating emotional settings in which eating occursoccurs

Provides feedback on progress and Provides feedback on progress and puts responsibility on the patientputs responsibility on the patient

Problem SolvingProblem Solving

Process for defining the eating or Process for defining the eating or weight problemweight problem

Generating possible solutions; Generating possible solutions; evaluating the solutions, choosing evaluating the solutions, choosing the best onethe best one

Trialing the new behavior, Trialing the new behavior, evaluating outcome and evaluating outcome and generating alternativesgenerating alternatives

Stimulus ControlStimulus Control

Modification ofModification of The settings or the chain of The settings or the chain of

events that precede eatingevents that precede eating The kinds of foods consumedThe kinds of foods consumed The consequences of eatingThe consequences of eating

– Become mindful of satiety cuesBecome mindful of satiety cues– Put fork down between bitesPut fork down between bites– Pausing during mealsPausing during meals

Cognitive Cognitive RestructuringRestructuring Teaches patients to identify, Teaches patients to identify,

challenge, and correct negative challenge, and correct negative thoughtsthoughts

Positive self-talkPositive self-talk

Behavior ModificationBehavior Modification

Most effective in mildly obese Most effective in mildly obese (20-40% overweight)(20-40% overweight)

Patients can maintain losses of Patients can maintain losses of 20-25 pounds20-25 pounds

Longer programs more successfulLonger programs more successful Many patients regain the weight Many patients regain the weight

they lost over timethey lost over time


Weight Loss Weight Loss MedicationsMedications

Pharmacological Pharmacological Therapy NIH Therapy NIH GuidelinesGuidelines Should be used only in the Should be used only in the

context of a program that context of a program that includes lifestyle changesincludes lifestyle changes

If lifestyle changes do not If lifestyle changes do not promote weight loss after 6 promote weight loss after 6 months, drugs should be months, drugs should be consideredconsidered

Limited to those with BMI ≥30; or Limited to those with BMI ≥30; or ≥27 with risk factors≥27 with risk factorsNIH NHLBI The practical guide. Identification, evaluation, and

treatment of overweight and obesity in adults. NHLBI, 2000

Wt Loss MedicationsWt Loss Medications

R.14.0 FDA-approved weight loss R.14.0 FDA-approved weight loss medications may be part of a comprehensive medications may be part of a comprehensive weight management program. weight management program.

Dietitians should collaborate with other Dietitians should collaborate with other members of the health care team regarding members of the health care team regarding the use of FDA-approved weight loss the use of FDA-approved weight loss medications for people who meet the NHLBI medications for people who meet the NHLBI criteria. criteria.

Research indicates that pharmacotherapy Research indicates that pharmacotherapy may enhance weight loss in some overweight may enhance weight loss in some overweight and obese adults. and obese adults. Strong, ImperativeStrong, Imperative


Catecholaminergic Catecholaminergic DrugsDrugs

Appetite suppressantsAppetite suppressants Act on the brain, increasing the Act on the brain, increasing the

availability of norepinephrineavailability of norepinephrine Schedule II anorexic agentsSchedule II anorexic agents

– High potential for abuseHigh potential for abuse– Include amphetamine, phenmetrazine HClInclude amphetamine, phenmetrazine HCl– Not recommended for weight managementNot recommended for weight management

Schedule III agentsSchedule III agents– Some potential for abuseSome potential for abuse– Include benzphetamine HCl, Include benzphetamine HCl,

phendimetrazine tartratephendimetrazine tartrate

See Table 21-5 Krause 12th edition, p. 551

Catecholaminergic Catecholaminergic DrugsDrugs Schedule IV agentsSchedule IV agents

– Includes diethypropion HCl, Includes diethypropion HCl, manzindol HCl, phentermine HCl, manzindol HCl, phentermine HCl, phentermine resinphentermine resin

– Low potential for abuseLow potential for abuse– Can raise blood pressure, so Can raise blood pressure, so

prescribed with caution in patients prescribed with caution in patients with hypertensionwith hypertension


Serotonin Reuptake Serotonin Reuptake InhibitorsInhibitors Includes sibutramine (Meridia)Includes sibutramine (Meridia) Inhibits the reuptake of serotonin Inhibits the reuptake of serotonin

and norepinephrineand norepinephrine Initially developed to treat Initially developed to treat

depressiondepression Use caution in hypertension, CHD, Use caution in hypertension, CHD,

arrhythmias, CHFarrhythmias, CHF


Orlistat (Xenical)Orlistat (Xenical)

Lipase inhibitorLipase inhibitor Acts directly on the gastrointestinal Acts directly on the gastrointestinal

tract to inhibit fat absorptiontract to inhibit fat absorption Associated with reduced LDL-C and Associated with reduced LDL-C and

increased HDL; improved glycemic increased HDL; improved glycemic control, reduced blood pressurecontrol, reduced blood pressure

Some concern about fat soluble Some concern about fat soluble vitaminsvitamins

Side effects: oily spotting, fecal Side effects: oily spotting, fecal urgency, flatus with dischargeurgency, flatus with discharge


FDA Approves Reduced FDA Approves Reduced Dose of Orlistat for Over the Dose of Orlistat for Over the CounterCounter Over the counter Over the counter

dose of orlistat, a dose of orlistat, a lipase inhibitorlipase inhibitor

Half the dose of Half the dose of prescription form prescription form (Xenical)(Xenical)

The only FDA-The only FDA-approved over the approved over the counter wt mgt drugcounter wt mgt drug

Available summer Available summer 20072007

Serotoninergic AgentsSerotoninergic Agents

Increase serotonin levels in the Increase serotonin levels in the brainbrain

Fenfluramine hydrochloride and Fenfluramine hydrochloride and dexfenfluramine HCl (Fen-Phen) dexfenfluramine HCl (Fen-Phen) were removed from the market in were removed from the market in 1997 due to association with 1997 due to association with heart valve disease and heart valve disease and pulmonary hypertensionpulmonary hypertension

Pharmacological Pharmacological Obesity TreatmentsObesity Treatments Weight loss of about 1 lb/week can Weight loss of about 1 lb/week can

be expectedbe expected Most weight loss will occur within Most weight loss will occur within

the first 6 months of therapythe first 6 months of therapy Significant weight maintenance as Significant weight maintenance as

long as the drug treatment is long as the drug treatment is continuedcontinued

Most patients regain weight if Most patients regain weight if medication is stoppedmedication is stopped

Pharmacological Pharmacological Obesity TreatmentsObesity Treatments Weight-loss medications lead to Weight-loss medications lead to

an additional weight loss of 5 to an additional weight loss of 5 to 22 pounds more than with non-22 pounds more than with non-drug obesity treatments drug obesity treatments

Two to 20 kg total loss, usually Two to 20 kg total loss, usually during first 6 months of treatmentduring first 6 months of treatment

When drugs are discontinued, When drugs are discontinued, weight regain occursweight regain occurs

Physical Activity and Physical Activity and Weight ManagementWeight Management

Physical ActivityPhysical Activity

R.12.0 Physical activity should be part of a R.12.0 Physical activity should be part of a comprehensive weight management comprehensive weight management program. Physical activity level should be program. Physical activity level should be assessed and individualized long-term goals assessed and individualized long-term goals established to accumulate at least 30 minutes established to accumulate at least 30 minutes or more of moderate intensity physical or more of moderate intensity physical activity on most, and preferably, all days of activity on most, and preferably, all days of the week, unless medically contraindicated. the week, unless medically contraindicated.

Physical activity contributes to weight loss, Physical activity contributes to weight loss, may decrease abdominal fat, and may help may decrease abdominal fat, and may help with maintenance of weight loss. with maintenance of weight loss. Strong, Strong, ImperativeImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

Physical Activity: NIH Physical Activity: NIH GuidelinesGuidelines Physical activity increases energy Physical activity increases energy

expenditure and plays an integral role expenditure and plays an integral role in weight maintenancein weight maintenance

Reduces the risk of heart disease more Reduces the risk of heart disease more than weight loss alonethan weight loss alone

Reduces body fat, prevents decrease Reduces body fat, prevents decrease in muscle mass during weight lossin muscle mass during weight loss

All adults: goal of 30 minutes or more All adults: goal of 30 minutes or more of moderate-intensity physical activity of moderate-intensity physical activity on most and preferably all days.on most and preferably all days.


Role of Physical Role of Physical Activity in Weight Activity in Weight ManagementManagement Physical activity usually will not Physical activity usually will not

lead to a greater weight loss over lead to a greater weight loss over diet alone in a 6-month period diet alone in a 6-month period (NIH, 2000)(NIH, 2000)

Physical activity is most helpful in Physical activity is most helpful in preventing weight regainpreventing weight regain

Physical activity also is beneficial Physical activity also is beneficial in reducing risk for heart disease in reducing risk for heart disease and diabetes beyond the effect of and diabetes beyond the effect of weight lossweight loss

Role of Physical Role of Physical Activity in Weight Activity in Weight ManagementManagement Exercise helps balance the loss of Exercise helps balance the loss of

LBM and reduction in RMR caused LBM and reduction in RMR caused by hypocaloric dietsby hypocaloric diets

A combination of aerobic exercise A combination of aerobic exercise and resistance training is and resistance training is recommendedrecommended

Even when weight loss does not Even when weight loss does not occur, loss of body fat often doesoccur, loss of body fat often does

May require 2 months to see loss May require 2 months to see loss of weight through exerciseof weight through exercise

U.S. Dietary Guidelines U.S. Dietary Guidelines 20052005 Suggest 60 minutes of moderate-Suggest 60 minutes of moderate-

vigorous activity on most days of the vigorous activity on most days of the week to prevent weight gain in week to prevent weight gain in adulthoodadulthood

To sustain weight loss in adulthood: at To sustain weight loss in adulthood: at least 60-90 minutes of daily moderate-least 60-90 minutes of daily moderate-intensity physical activity intensity physical activity

Achieve physical fitness by including Achieve physical fitness by including cardiovascular conditioning, stretching cardiovascular conditioning, stretching exercises for flexibility, and resistance exercises for flexibility, and resistance exercises or calisthenics for muscle exercises or calisthenics for muscle strength and endurance. strength and endurance. http://www.health.gov/dietaryguidelines/dga2005/recommendations.htm

Role of Physical Role of Physical Activity in Weight Activity in Weight ManagementManagement

Other Benefits: Other Benefits:

——Improved sense of well-beingImproved sense of well-being

——Relief of boredomRelief of boredom

——Sense of controlSense of control

——Relief from depressionRelief from depression

Bariatric SurgeryBariatric Surgery

R.15.0. Dietitians should collaborate R.15.0. Dietitians should collaborate with other members of the health care with other members of the health care team regarding the appropriateness of team regarding the appropriateness of bariatric surgery for people who have bariatric surgery for people who have not achieved weight loss goals with less not achieved weight loss goals with less invasive weight loss methods and who invasive weight loss methods and who meet the NHLBI criteria. meet the NHLBI criteria.

Separate ADA evidence based Separate ADA evidence based guidelines are being developed on guidelines are being developed on nutrition care in bariatric surgery. nutrition care in bariatric surgery. Strong, ImperativeStrong, Imperative


Bariatric Surgery: NIH Bariatric Surgery: NIH GuidelinesGuidelines Option for well-informed and Option for well-informed and

motivated patients with clinically motivated patients with clinically severe obesity (BMI≥40 or BMI severe obesity (BMI≥40 or BMI ≥35 with serious co-morbid ≥35 with serious co-morbid conditionsconditions


Candidates for Candidates for Bariatric SurgeryBariatric Surgery BMI of 40 or more—about 100 pounds BMI of 40 or more—about 100 pounds

overweight for men and 80 pounds for overweight for men and 80 pounds for women women

BMI between 35 and 39.9 and a BMI between 35 and 39.9 and a serious obesity-related health problem serious obesity-related health problem such as type 2 diabetes, heart disease, such as type 2 diabetes, heart disease, or severe sleep apneaor severe sleep apnea

Willingness to make associated Willingness to make associated lifestyle changes lifestyle changes

Bariatric Surgery Bariatric Surgery OptionsOptions RestrictiveRestrictive MalabsorptiveMalabsorptive Combination Combination

restrictive/malabsorptiverestrictive/malabsorptive

Restrictive ProceduresRestrictive Procedures

Adjustable gastric banding (AGB)Adjustable gastric banding (AGB) a a hollow band made of silicone rubber is hollow band made of silicone rubber is placed around the stomach near its placed around the stomach near its upper end, creating a small pouch and a upper end, creating a small pouch and a narrow passage into the rest of the narrow passage into the rest of the stomach stomach

Vertical banded gastroplasty.Vertical banded gastroplasty. VBG VBG uses both a band and staples to create a uses both a band and staples to create a small stomach pouch (not often used small stomach pouch (not often used today)today)

Restrictive Surgery: Restrictive Surgery: Adjustable Gastric Adjustable Gastric BandBand

Diet After SurgeryDiet After Surgery

After restrictive surgeries, After restrictive surgeries, patients can only eat ½ cup to 1 patients can only eat ½ cup to 1 cup of food at a timecup of food at a time

Foods often must be soft and Foods often must be soft and chewed thoroughlychewed thoroughly

Patients who eat too fast or the Patients who eat too fast or the wrong kinds of food may have wrong kinds of food may have vomitingvomiting

Restrictive Restrictive Procedures: Procedures: AdvantagesAdvantages Don’t interfere with the normal Don’t interfere with the normal

digestive processdigestive process Easier to perform and generally Easier to perform and generally

safer than malabsorptive safer than malabsorptive surgeriessurgeries

AGB often done laparoscopicallyAGB often done laparoscopically Can be reversed if necessaryCan be reversed if necessary

Restrictive Restrictive Procedures: Procedures: DisadvantagesDisadvantages Generally results in less weight lossGenerally results in less weight loss Patients generally lose about half of Patients generally lose about half of

their excess body weight in the first their excess body weight in the first year after restrictive procedures year after restrictive procedures

Only 20% keep weight off over 10 Only 20% keep weight off over 10 years, though there is evidence that years, though there is evidence that AGB is more effective than VBGAGB is more effective than VBG

Restrictive/Restrictive/Malabsorptive Malabsorptive ProceduresProcedures Roux-en-Y gastric bypass (RGBRoux-en-Y gastric bypass (RGB) is the ) is the

most commonmost common The surgeon creates a small stomach The surgeon creates a small stomach

pouch to restrict food intake. Next, a Y-pouch to restrict food intake. Next, a Y-shaped section of the small intestine is shaped section of the small intestine is attached to the pouch to allow food to attached to the pouch to allow food to bypass the lower stomach, the bypass the lower stomach, the duodenum and the first portion of the duodenum and the first portion of the jejunum. jejunum.

This reduces the amount of calories and This reduces the amount of calories and nutrients the body absorbs. nutrients the body absorbs.

Restrictive/Restrictive/Malabsorptive: Roux en Malabsorptive: Roux en YY

Restrictive/Restrictive/Malabsorptive Malabsorptive Procedures: Procedures: AdvantagesAdvantages Patients lose weight quickly and Patients lose weight quickly and

continue to lose 18-24 months continue to lose 18-24 months after the procedureafter the procedure

With RGB, many patients With RGB, many patients maintain a weight loss of 60 to 70 maintain a weight loss of 60 to 70 percent of their excess weight for percent of their excess weight for 10 years or more 10 years or more

Restrictive/Malabsorptive Restrictive/Malabsorptive Procedures: Procedures: DisadvantagesDisadvantages More difficult to performMore difficult to perform More likely to result in long-term More likely to result in long-term

nutritional deficiencies (calcium, nutritional deficiencies (calcium, iron)iron)

Greater risk of dumping syndromeGreater risk of dumping syndrome Increased likelihood of complications Increased likelihood of complications

including hernia (decreased with including hernia (decreased with laparoscopic procedures)laparoscopic procedures)

Weight Management—Weight Management—ChildrenChildren

Goals: Weight maintenance or Goals: Weight maintenance or slowing of gainsslowing of gains

Grow into weightGrow into weight If severely obese, lose no more If severely obese, lose no more

than 1 lb monthly to reach than 1 lb monthly to reach desired adult weight for heightdesired adult weight for height

Weight Management in Weight Management in ChildrenChildren At risk at BMI 85% to 95%ile; At risk at BMI 85% to 95%ile;

obese at 95%obese at 95% Review parents’ history—Review parents’ history—

height, weight, etc.height, weight, etc. Weight management in children Weight management in children

is a family affairis a family affair

Weight Management in Weight Management in ChildrenChildren Overweight children should try to Overweight children should try to

achieve weight maintenance or achieve weight maintenance or slowing of the rate of weight gain, slowing of the rate of weight gain, not weight lossnot weight loss

Depends on age and degree of Depends on age and degree of overweightoverweight

Once adult height is achieved, Once adult height is achieved, weight loss is necessary to weight loss is necessary to improve healthimprove health

SummarySummary

Even modest weight loss can Even modest weight loss can produce improvements in produce improvements in overall health in persons who overall health in persons who are overweight (lipids, BG, are overweight (lipids, BG, insulin, blood pressure)insulin, blood pressure)

Most persons will need Most persons will need sustained, long-term lifestyle sustained, long-term lifestyle interventions to achieve interventions to achieve significant weight losssignificant weight loss

weight management medical and nutritional therapy

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