Obesity in Adults: Treatment and Management

1. Obesity in Adults:Treatment and Management Gary D. Foster, PhD Clinical Director, Weight and Eating Disorders Program Assistant Professor, Department of Psychiatry University of Pennsylvania School of Medicine

2. 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.

3. Treatment of Obesity • Behavioral • Pharmacological • Surgical • Self help programs and books

4. Behavioral Treatment Philosophy • Consists of a set of principles and techniques to modify eating and activity habits. • Emphasizes small and sustainable changes.

5. 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

6. Behavioral Treatment Methods • Self-monitoring • Recording food intake/evaluating nutrients • Recording physical activity • Stimulus control techniques • Time • Place • Activity • Sight/smell • Emotions

7. 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.

8. 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

9. Behavioral Treatment Results • 10% reduction over 20 to 24 weeks • 33% regain at one year • More weight regained over time

10. Improving Weight-loss Maintenance • Continued care • Sustaining dietary changes • Exercise • Pharmacotherapy

11. Treatment of ObesityPharmacological Therapy • Pharmacological interventions to facilitate weight loss and behavior change include: • Enhancing satiety • Decreasing fat absorption • Increasing energy expenditure • Decrease appetite

12. 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

13. 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.

14. Sibutramine (Meridia)Summary of Reported Adverse Event Package insert data, Sibutramine, 1998.

15. 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.

16. 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.

17. Orlistat (Xenical)Summary of Research Findings Sjostrom L et al. Lancet 1998;352:167-172.

18. Orlistat (Xenical)Summary of Reported Adverse Events Package insert data, Orlistat, 1998.

19. 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.

20. 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.

21. 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.

22. Staple Line Pouch Band Fundus 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.

23. Staple Line Pouch Fundus Jejunum 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.

24. 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.

25. 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

26. 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.

27. 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.

28. 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

29. 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.

30. 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.

31. 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.

32. 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.

33. 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.

34. 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).

35. Improving Weight-loss Maintenance • Continued care • Exercise • Pharmacotherapy • Other

36. 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

37. 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.

38. 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.

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

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

41. Dream = 0% Happy9% Acceptable 24% Did not Reach Disappointed Weight 47% Disappointed 20% Percent Achieving DefinedWeight at Week 48 (n=45) Weight loss: 16.3 ± 7.2 kg Foster GD, et al. J Consult Clin Psychol 1997;65:79-85.

42. 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.