Transcript NHM 555 - Pennington Biomedical Research Center

Treatment of Obesity
Pennington Biomedical Research
Center
Division of Education
Treatment options
 When does obesity threaten the health
and life of a patient?
 Which patients have co-morbidities
that make an aggressive treatment
necessary?
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Steps in determining treatment
 Determine BMI.
 Assess complications and risk factors
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Steps in determining treatment
 Determine BMI-related health risk
 Determine weight reduction
exclusions
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Mental illness
Unstable medical condition
Some medications
Temporary
 Pregnancy or lactation
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Steps in determining treatment
 Possible exclusions
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Osteoporosis
BMI in minimal or no-risk category
History of mental illness
Medications
 Permanent exclusions
 Anorexia nervosa
 Terminal illness
 Assess patient readiness
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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
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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.
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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.
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Dieting with the Exchange List
Food is broken down into 6 categories:
Starch/Bread
Meat
Vegetables
Fruit
Milk
Fat
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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.
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Exchanges for Various Calorie Levels
Total
Kcal/
d
Meat
Bread/
starch
Vegs
Fats
Fruit
Skim
milk
(cups)
2%
milk
1200 1400 1500 1600 1700 1800 2000 2100 2200
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Example of daily exchange diet:
1800 Kcals daily
BREAKFAST
1 c orange juice
2 slices of toast
1 hard-cooked egg
2 tsp margarine
1 c 2% milk
Coffee or tea
Yields
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2 Fruits
2 Breads
1 Meat
2 Fat
1 Milk
Free Food
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Example of daily exchange diet:
1800 Kcals daily
LUNCH
½ c tuna
2 slices whole wheat bread
½ c tomato slices
Lettuce/cucumber salad
Yields
1 c sliced peaches
1 tsp margarine
Tea with lemon
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2 Meat
2 Bread
1 Vegetable
Raw Vegetable
2 Fruit
2 Fat
Free Foods
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Example of daily exchange diet:
1800 Kcals daily
3 oz baked chicken
DINNER
½ c mashed potato
1 small whole grain roll
½ c broccoli, ½ c carrots
Yields
Tossed salad
1 Tbsp salad dressing
1 tsp margarine
Coffee
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3 meat
1 Bread
1 Bread
1 Vegetable
Raw Vegetable
1 Fat
1 Fat
Free Food
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Example of daily exchange diet:
1800 Kcals daily
EVENING
SNACK
2 graham crackers
1 c 2% milk
1 Bread
1 Milk
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The Exchange Diet
For more information please visit:
http://www.diabetes.org/home.jsp
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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
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Meal Replacement Plan
4 types of meal replacers:
Powder mixes
Shakes
Bars
Prepackaged Meals
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Meal Replacement Plan
An intake of five fruits and vegetables is
recommended.
 Effective
 Convenient
 Nutritionally balanced
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Example:
A MEAL REPLACEMENT PLAN
Breakfast
Meal Replacement
Lunch
Sensible Meal or Meal
Replacement
Dinner
Sensible Meal
Snacks
Fruit, vegetable, fatfree yogurt or cheese,
nuts, pretzels, or airpopped popcorn
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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
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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
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Exercise
Energy Balance = maintaining
weight.
Positive energy balance leads to
weight gain.
Negative energy balance leads to
weight loss.
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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.
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Exercise
For Weight Loss
 150 to 200 minutes of moderate physical activity
each week
 diet for weight loss
For Improved Health
An exercise program with less than 150 minutes a
week and lower intensity can result in improvement
in cardio-respiratory fitness.
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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
Racket sports
Swimming
Lawn mowing
Aerobic dancing
Ice or roller skating
Using aerobic equipment
(treadmill, stationary bike)
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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.
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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.
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VLCD: Facts
 Not recommended for pregnant or breastfeeding
women
 Not appropriate for children or adolescents
 Not recommended for older individuals
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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
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Group Approaches
 Social support
 integration into social network and positive
interactions with others.
 Individual feels support, acceptance, and
encouragement by others.
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Behavior Treatment
 Need to change one’s approach
 thinking
 feelings
 actions
to eating and physical activity.
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Behavioral targets
Weight =
Total energy
intake
_
Eating
Activity
Total energy
expenditure
Targets of behavioral therapy
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Behavior Therapy:
Important Components
1. Making Lifestyle Change a Priority
2. Establishing a Plan for Success
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Behavior Therapy:
Important Components
3. Setting Goals
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Calories, fat, physical activity.
Short-term goal of losing 1 to 2 pounds a week.
Choose specific, attainable, and realistic goals.
Have a long-term goal.
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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.
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Behavior Therapy:
Important Concepts
5. Avoiding a Food Chain Reaction
 Stimulus control.
 Learning to recognize cues.
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Behavior Therapy:
Important Concepts
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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
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Behavior Therapy:
Important Concepts
6. Changing Eating and Activity Patterns
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slowing pace of eating
reducing portion sizes
measuring food intake
leaving food on plate
improving food choices
eliminating second servings
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Behavior Therapy:
Important Concepts
Changing Eating and Activity Patterns
 Programmed exercise vs lifestyle
 Lifestyle activity preferable for weight
loss.
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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
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Behavior Therapy:
Important Concepts
8. Cognitive Behavioral Strategies
 Traditional behavioral treatment components
with emphasis on thinking patterns that may
affect eating behaviors.
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Behavior Therapy:
Important Concepts
9. Stress Management
 Stress is a primary predictor of
overeating and relapse.
 Stress management skills
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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
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Drug Therapy
Commonly prescribed drugs for the
treatment of obesity include:
Phentermine
Sibutramine
Orlistat
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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.
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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.
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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.
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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
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Types of GI surgeries
available
Restrictive
Malabsorptive
Combined restrictive/malabsorptive
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GI Surgeries: Restrictive
Purely restrictive operations only limit food intake and
do not interfere with the normal digestive process.
Create a pouch.
Delay in food emptying.
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Restrictive Operations: Examples
1.
Adjustable gastric banding
A band is clamped to create a pouch.
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Restrictive Operations: Examples
2. Vertical banded gastroplasty.
Uses the band and staples to create
a small pouch. Not commonly used
today.
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Restrictive Operations:
Advantages
1. Generally safer than malabsorptive
procedures.
2. Done via laparoscopy allowing for
smaller incisions.
3. Surgeries can be reversed if necessary.
4. Result in few nutritional deficiencies.
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Restrictive Operations:
Disadvantages
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Smaller weight loss.
Can lead to weight gain over time.
No change in eating habits.
Success depends on the patient’s
willingness to adopt a healthy
lifestyle.
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Restrictive Operations: Risks
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3.
Overeating leading to vomiting.
Break in tubing.
Problems leading to a second operation.
These risks need to be taken into account
by any individual considering the
surgery!
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Malabsorptive Operations
 The main malabsorptive operation is the
jejunoileal bypass which is not
performed today because of the high
incidence of health complications.
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Combined Restrictive and
Malabsorptive Operations
Restricts both food intake and the amount of
calories and nutrients the body absorbs.
Roux-en-Y gastric bypass (RGB)
Creates a pouch.
Connects the small intestine
to the pouch, bypassing large
sections of the intestines.
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Combined Restrictive and
Malabsorptive Operations
Biliopancreatic diversion (BPD)
Remove portion of stomach.
Connect this directly to the
final segment of the small intestine
completely bypassing sections of
intestines.
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Combined Operations:
Advantages
1. Rapid weight loss.
2. Maintain good weight loss for 10 years or
more.
3. Can lose up to 75-80% of excess weight.
4. May lead to greater improvement in
health.
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Combined Operations:
Disadvantages
1.
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Can be difficult.
May result in long-term nutritional
deficiencies.
Decreased absorption of iron and calcium.
Require fat soluble vitamin
supplementation.
May have dumping syndrome.
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Combined Operations: Risks
1.
2.
3.
May lead to complications.
Greater risk for abdominal hernias.
The risk of death may be higher.
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Bariatric Surgery: Facts
Procedures cost from $20,000 to $35,000.
Medical insurance coverage varies by state.
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NIDDK
(National Institute of Diabetes and Digestive and Kidney
Diseases)
The patient should consider the following
questions prior to weight loss surgery:
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2.
3.
Are you unlikely to lose weight or keep weight
off long-term with non-surgical measures?
Are you well informed about the surgical
procedure and the effects of treatment?
Are you determined to lose weight and
improve your health?
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NIDDK
4. Are you aware of how your life may change
after the operation?
5. Are you aware of the potential for serious
complications, dietary restrictions, and
occasional failures?
6. Are you committed to lifelong medical followup and vitamin/mineral supplementation?
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Conclusions
 When there are no complications or comorbidities associated with obesity,
dietary, exercise and behavioral
approaches are the safest and best
approaches.
 For successful weight loss to become
permanent, an individual has to adopt new
behaviors to maintain weight loss.
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Conclusion
 It is very important for individuals considering
initiation of weight loss drug therapy or surgeries
to be well aware of the risks associated with the
treatments.
 Once all risks are understood, then ultimately it
is the individual’s decision to go along with the
treatment or not.
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References: Behavior Therapy and
VLCD Information
 http://www.medhelp.org/NIHlib/GF-390.html
 Foreyt, J.P., & Poston, W.S.C., Jr. (1998a). The role of the
behavioral counselor in obesity treatment. J Am Diet Assoc,
10(Supplement 2), S27-S30
 Foreyt, J.P., & Poston, W.S.C., Jr. (1998b). What is the role of
cognitive-behavior therapy in patient management? Obes Res,
6(Supplement 1), 18S-22S
 Foster, G.D., Wadden, T.A., Vogt, R.A., & Brewer, G. (1997).
What is a reasonable weight loss? Patients' expectations and
evaluations of obesity treatment outcomes. J Consult Clin
Psychol, 65, 79-85
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References : Behavior therapy
 Poston, W.S.C., Jr., Hyder, M.L., O'Byrne, K.K., & Foreyt,
J.P. (2000). Where do diets, exercise, and behavior
modification fit in the treatment of obesity? Endocrine,
13(2), 187-192.
 Wadden, T.A., Sarwer, D.B., & Berkowitz, R.I. (1999).
Behavioural treatment of the overweight patient. Baillieres
Best Pract Res Clin Endocrinol Metab, 13(1), 93-107.
 Wing, R.R. (1993). Behavioral approaches to the
treatment of obesity. In G. Bray, C. Bouchard & P. James
(Eds.), Handbook of Obesity (pp. 855-873). New York:
Marcel Dekker, Inc.
 Wing, R.R., & Tate, D.F. (2002). Behavior modification for
obesity. In J.F. Caro (Ed.), Obesity.
http://www.endotext.org/obesity/index.htm:
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Sites: Drug Therapy Info & Surgery
 http://www.cdc.gov
 National Heart, Lung, and Blood Institute, Clinical Guidelines
on the Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults, 1998.
 Astrup A, Hansen DL, Lundsgaard C, Toubro S. Sibutramine
and energy balance. Int J Obes Relat Metab Disord 1998
Aug; 22 Suppl 1: S30-S35.
 Bray GA, Ryan DH, Gordon D, et al. A double-blind
randomized placebo-controlled trial of sibutramine. Obes Res
1996 May; 4(3): 263-70.
 Heal DJ, Aspley S, Prow MR, et al. Sibutramine: a novel antiobesity drug. A review of the pharmacological evidence to
differentiate it from d-amphetamine and d-fenfluramine. Int J
Obes Relat Metab Disord 1998 Aug; 22 Suppl 1: S18-S29.
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References: Drug therapy &
Surgery
 www.meridia.net
 Waitman, JA, Aronne LJ. Phrmacotherpay of obesity.
Obesity Management 1: 15-19, 2005.
 Greenway, F. Surgery for obesity. Endocrinology and
Metabolism Clinics of North America 25(4):1005-1027.
 Surgery for morbid obesity: What patients should know. 3rd
Ed. American Society for BariatricSurgery, Gainesville, FL
2001.
 http://win.niddk.nih.gov/publications/gastric.htm
 Escott-Stump, S. Nutrition and Diagnosis-Related Care. 5th
Edition. 2002.
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References: Exercise
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http://www.cdc.gov
Ross R, Jansses I, Dawson J, Kungl A-M, Kuk JL, Wong SL,
Nguyen-Day T-B, Lee SL, Kilpatrick K, Hudson R. Exercise
induced reduction in obesity and insulin resistance in women: a
randomized controlled trial. Obesity Research 12:789-798, 2004.
Jakicic JM, Marcus BH, Gallagher KI, Napolitano M, Lang W.
Effects of exercise duration and intensity on weight loss in
overweight, sedentary women. JAMA 10: 1323-1330, 2003.
Ross R, Katzmarzyk PT. Cardio respiratory fitness is associated
with diminished total and abdominal obesity independent of body
mass index. International Journal of Obesity 27: 204-210, 2003.
McArdle WD, Katch FL, and Katch VL. Exercise Physiology:
Energy, Nutrition and Human Performance, 5th Edition. Lippincott
Williams & Wilkins 2004.
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References: Diet
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http://www.cdc.gov
Noakes M, Foster PR, Keogh JB, Clifton PM. Meal replacements
are as effective as structured weight-loss diets for treating obesity in
adults with features of metabolic syndrome. J Nutr. 2004
Aug;134(8):1894-9.
Truby H, Millward D, Morgan L, Fox K, Livingstone MB, DeLooy A,
Macdonald I. A randomised controlled trial of 4 different commercial
weight loss programmes in the UK in obese adults: body
composition changes over 6 months.
Asia Pac J Clin Nutr. 2004 Aug;13(Suppl):S146.
http://www.slim-fast.com/plan/index.asp?bhcp=1 Accessed
September 16, 2004.
Halford JCG, Ball MF, Pontin EE, Maharjan LB, Dovey TM, Pinkney
JH, Wilding JPH, Mela DJ. The impact of using meal-replacements
versus standard dietetic advice on body weight, appetite, mood, and
satisfaction during a 12-week weight control. North American
Association for the Study of Obesity Conference, November 14-18,
2004, Las Vegas, Nevada.
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Pennington Biomedical
Research Center
Division of Education
 Heli J. Roy, PhD, RD
 Beth Kalicki
 Division of Education
Phillip Brantley, PhD, Director
Pennington Biomedical Research Center
Claude Bouchard, PhD, Executive Director
Edited: October 2009
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About Our Company…
The Pennington Biomedical Research Center is a world-renowned nutrition research center.
Mission:
To promote healthier lives through research and education in nutrition and preventive medicine.
The Pennington Center has several research areas, including:
Clinical Obesity Research
Experimental Obesity
Functional Foods
Health and Performance Enhancement
Nutrition and Chronic Diseases
Nutrition and the Brain
Dementia, Alzheimer’s and healthy aging
Diet, exercise, weight loss and weight loss maintenance
The research fostered in these areas can have a profound impact on healthy living and on the prevention of common chronic diseases,
such as heart disease, cancer, diabetes, hypertension and osteoporosis.
The Division of Education provides education and information to the scientific community and the public about research findings,
training programs and research areas, and coordinates educational events for the public on various health issues.
We invite people of all ages and backgrounds to participate in the exciting research studies being conducted at the Pennington Center
in Baton Rouge, Louisiana. If you would like to take part, visit the clinical trials web page at www.pbrc.edu or call (225) 763-3000.
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