Treatment of Obesity

1. Treatment of Obesity Pennington Biomedical Research Center Division of Education

2. Treatment options • When does obesity threaten the health and life of a patient? • Which patients have co-morbidities that make an aggressive treatment necessary? 2009

3. Steps in determining treatment • Determine BMI. • Assess complications and risk factors 2009

4. Steps in determining treatment • Determine BMI-related health risk • Determine weight reduction exclusions • Mental illness • Unstable medical condition • Some medications • Temporary • Pregnancy or lactation 2009

5. Steps in determining treatment • Possible exclusions • Osteoporosis • BMI in minimal or no-risk category • History of mental illness • Medications • Permanent exclusions • Anorexia nervosa • Terminal illness • Assess patient readiness 2009

6. Steps in determining treatment Treatment Options 1. Mild energy-deficit regimen Diet, diet and exercise, behavioral therapy 2. Aggressive energy-deficit regimen VLCD Extensive exercise program 3. Obesity drugs 4. Surgery More extreme options 2009

7. Dietary treatment When someone is a few pounds overweight and is motivated to lose weight, dietary approach is a safe and effective method for weight loss. It is also the best method for helping to acquire new skills for maintaining a weight loss. 2009

8. Dieting with the Exchange List • The Exchange diet. • Monitor intake of carbohydrates, fat and protein as well as portion sizes. • Includes foods from each group and can be used indefinitely. • It also works well in weight maintenance. 2009

9. Dieting with the Exchange List Food is broken down into 6 categories: Starch/Bread Meat Vegetables Fruit Milk Fat 2009

10. The Exchange List • The number of exchanges is determined by the total number of calories required. • Different for each person and depends on: • height, weight, and energy expenditure. 2009

11. Exchanges for Various Calorie Levels

12. 1 c orange juice 2 slices of toast 1 hard-cooked egg 2 tsp margarine 1 c 2% milk Coffee or tea 2 Fruits 2 Breads 1 Meat 2 Fat 1 Milk Free Food Example of daily exchange diet: 1800 Kcals daily BREAKFAST Yields 2009

13. ½ c tuna 2 slices whole wheat bread ½ c tomato slices Lettuce/cucumber salad 1 c sliced peaches 1 tsp margarine Tea with lemon 2 Meat 2 Bread 1 Vegetable Raw Vegetable 2 Fruit 2 Fat Free Foods Example of daily exchange diet: 1800 Kcals daily LUNCH Yields 2009

14. 3 oz baked chicken ½ c mashed potato 1 small whole grain roll ½ c broccoli, ½ c carrots Tossed salad 1 Tbsp salad dressing 1 tsp margarine Coffee 3 meat 1 Bread 1 Bread 1 Vegetable Raw Vegetable 1 Fat 1 Fat Free Food Example of daily exchange diet: 1800 Kcals daily DINNER Yields 2009

15. 2 graham crackers 1 c 2% milk 1 Bread 1 Milk Example of daily exchange diet: 1800 Kcals daily EVENING SNACK 2009

16. The Exchange Diet For more information please visit: http://www.diabetes.org/home.jsp 2009

17. Dieting Using Calorie Controlled Portions MEAL REPLACEMENT PLAN • Liquid formula or a packaged item • Fixed number of calories to replace a meal. • Control portion sizes • Fat, carbohydrate, calories • Balanced meals 2009

18. Meal Replacement Plan 4 types of meal replacers: Powder mixes Shakes Bars Prepackaged Meals 2009

19. Meal Replacement Plan An intake of five fruits and vegetables is recommended. • Effective • Convenient • Nutritionally balanced 2009

20. Example:A MEAL REPLACEMENT PLAN 2009

21. Exercise • Adults: 30-45 minutes of exercise three to five days each week • Include 5-10 minute warm up and cool down • Weight loss: at least 30 minutes of aerobic activity a day for five days 2009

22. Exercise • Children: at least 60 minutes, and up to several hours of physical activity per day for children and adolescents • Several bouts of physical activity lasting 15 minutes or more each day 2009

23. Exercise Energy Balance = maintaining weight. Positive energy balance leads to weight gain. Negative energy balance leads to weight loss. 2009

24. Exercise: Benefits Exercise builds lean body mass. Walking, running and doing physical activity can burn two to three times more calories than similar amount of time sitting. With exercise there is an improvement in overall physical fitness. Exercise improves maintenance of weight after weight loss. 2009

25. Exercise For Weight Loss • 150 to 200 minutes of moderate physical activity each week • diet for weight loss For Improved Health An exercise programwith less than 150 minutes a week and lower intensity can result in improvement in cardio-respiratory fitness. 2009

26. Aerobic Activity Aerobic exercise is any extended activity that makes the lungs and heart work harder while using the large muscle groups in the arms and legs at a regular, even pace. EXAMPLES  Brisk walking Jogging Bicycling Swimming Aerobic dancing Racket sports Lawn mowing Ice or roller skating Using aerobic equipment (treadmill, stationary bike) 2009

27. Anaerobic Activity Anaerobic activity is short bursts of very strenuous activity using large muscle groups (Ex: weight lifting, curls, power lifting). Helps build and tone muscles, but it does not benefit the heart or the lungs. 2009

28. Very Low Calorie Diets (VLCD) • Formula diet of 800 calories or less. • Must be under proper medical supervision. • Produce significant weight loss in moderately to severely obese patients. 2009

29. VLCD: Facts • Not recommended for pregnant or breastfeeding women • Not appropriate for children or adolescents • Not recommended for older individuals 2009

30. Behavioral Treatment • Widely used strategy • Based on adjusting energy balance • Individual treatment, or • Group Format • (Around 18-24 weeks) • One of the most successful treatment programs 2009

31. Group Approaches • Social support • integration into social network and positive interactions with others. • Individual feels support, acceptance, and encouragement by others. 2009

32. Behavior Treatment • Need to change one’s approach • thinking • feelings • actions to eating and physical activity. 2009

33. Behavioral targets Total energy intake Total energy expenditure _ Weight = Eating Activity Targets of behavioral therapy 2009

34. Behavior Therapy: Important Components • Making Lifestyle Change a Priority • Establishing a Plan for Success 2009

35. Behavior Therapy: Important Components 3.Setting Goals • Calories, fat, physical activity. • Short-term goal of losing 1 to 2 pounds a week. • Choosespecific, attainable, and realistic goals. • Have a long-term goal. 2009

36. Behavior Therapy: Important Concepts 4. Keeping Track of Eating and Exercising • Tracking to raise awareness. • Self monitoring. • Record time, activating event, place and quantity of eating, and activity behaviors. 2009

37. Behavior Therapy: Important Concepts 5. Avoiding a Food Chain Reaction • Stimulus control. • Learning to recognize cues. 2009

38. Behavior Therapy: Important Concepts Techniques to conquer eating triggers include: • eating regular meals • eating at the same time and place • use smaller plates • keeping accessible food out of sight • eating only when hungry • avoiding activities that encourage eating 2009

39. Behavior Therapy: Important Concepts 6. Changing Eating and Activity Patterns • slowing pace of eating • reducing portion sizes • measuring food intake • leaving food on plate • improving food choices • eliminating second servings 2009

40. Behavior Therapy: Important Concepts Changing Eating and Activity Patterns • Programmed exercise vs lifestyle • Lifestyle activity preferable for weight loss. 2009

41. Behavior Therapy: Important Concepts 7. Contingency Management • Positive reinforcement (reward) • An effective reward - immediate, desirable, and given based on meeting a specific goal. • Tangible rewards - a new CD • Intangible reward – taking time off 2009

42. Behavior Therapy: Important Concepts 8. Cognitive Behavioral Strategies • Traditional behavioral treatment components with emphasis on thinking patterns that may affect eating behaviors. 2009

43. Behavior Therapy: Important Concepts 9. Stress Management • Stress is a primary predictor of overeating and relapse. • Stress management skills 2009

44. Drug Treatment of Obesity:Indicated when • BMI is greater than 30 • BMI is higher than 27 and there are other cardiovascular complications • After several attempts diet alone is not enough Cardiovascular complications include: Hypertension, Dyslipidemia, Coronary Heart Disease, Type 2 Diabetes, and Sleep Apnea 2009

45. Drug Therapy Commonly prescribed drugs for the treatment of obesity include: Phentermine Sibutramine Orlistat 2009

46. Drug Therapy: Phentermine Brand names are Adipex-P, Obenix, Oby-Trim Most commonly prescribed medication for weight loss. Phentermine increases norepinephrine, a neurotransmitter in the brain that decreases appetite. Phentermine has stimulant properties, and it may cause high blood pressure or irregular heat beats. 2009

47. Drug Therapy: Sibutramine The brand name is Meridia Sibutramine induces weight loss by reducing food intake. It stimulates the satiety centers in the brain. Sibutramine use may increase heart rate and blood pressure. Sibutramine is not recommended for someone with uncontrolled hypertension, tachycardia, or serious heart, liver, or kidney disease. 2009

48. Drug Therapy:Orlistat The Brand name is Xenical Orlistat prevents the digestion of dietary fat. Bowel habits will likely change. Leads to improvement in blood lipids. Multivitamin supplement is encouraged. 2009

49. Surgical Treatment of Obesity Criteria used for surgical treatment: • BMI is 40 or higher • BMI of 35-39.9 and a serious obesity-related health problem such as: Type 2 diabetes, hypertension, heart disease, or sleep apnea 2009

50. Types of GI surgeries available Restrictive Malabsorptive Combined restrictive/malabsorptive 2009