Transcript Obesity in Adults: Causes, Consequences and Treatment

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
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine
Treatment of Obesity
 Behavioral
 Pharmacological
 Surgical
 Self help programs and books
© 2000 University of Pennsylvania School of Medicine
Behavioral Treatment Philosophy
 Consists of a set of principles and techniques
to modify eating and activity habits.
 Emphasizes small and sustainable changes.
© 2000 University of Pennsylvania School of Medicine
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
© 2000 University of Pennsylvania School of Medicine
Behavioral Treatment Methods
 Self-monitoring

Recording food intake/evaluating nutrients

Recording physical activity
 Stimulus control techniques

Time

Place

Activity

Sight/smell

Emotions
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine
Behavioral Treatment Methods
Increasing Physical Activity
 Identify barriers

Lack of time

Lack of motivation

Increased safety concerns
 Prescribe small changes

Take the stairs
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Gardening

Walking during work
© 2000 University of Pennsylvania School of Medicine
Behavioral Treatment Results
 10% reduction over 20 to 24 weeks
 33% regain at one year
 More weight regained over time
© 2000 University of Pennsylvania School of Medicine
Improving Weight-loss
Maintenance
 Continued care
 Sustaining dietary
changes
 Exercise
 Pharmacotherapy
© 2000 University of Pennsylvania School of Medicine
Treatment of Obesity
Pharmacological Therapy
 Pharmacological interventions to facilitate
weight loss and behavior change include:

Enhancing satiety

Decreasing fat absorption

Increasing energy expenditure

Decrease appetite
© 2000 University of Pennsylvania School of Medicine
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
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine
Sibutramine (Meridia)
Summary of Reported Adverse Event
Percent (%) of Patients
Adverse Event
Placebo (n = 884)
Sibutramine (n=2068)
Dry mouth
4
17
Anorexia
4
13
Constipation
6
12
Insomnia
5
11
Appetite increase
3
9
Dizziness
4
7
Nausea
3
6
Package insert data, Sibutramine, 1998.
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine
Orlistat (Xenical)
Summary of Research Findings
0
0
Placebo
Orlistat
% Wt Loss
-2
-4
-4.6
-6
-6.1
-7.8
-8
-10
-10.2
-12
0
1
2
Time (years)
Sjostrom L et al. Lancet 1998;352:167-172.
© 2000 University of Pennsylvania School of Medicine
Orlistat (Xenical)
Summary of Reported Adverse Events
Adverse Events
Overall Incidence
(% of Patients)
Oily spotting
26.6
Flatus with discharge
23.9
Fecal urgency
22.1
Oily stool
20.0
Oily evacuation
11.9
Increased defecation
10.8
Fecal incontinence
7.7
Package insert data, Orlistat, 1998.
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine
Surgical Treatment of Obesity
 Patient selection criteria

BMI > 40 or > 35 for those with weight related co-morbidities.
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History of failed conservative weight loss approaches.
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No substance abuse and/or psychiatric disorders.
 Surgical options
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Vertical banded gastroplasty (VBG)
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Gastric bypass (GBP)
 Outcomes
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Weight loss is 25% to 35% of initial weight.
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Weight loss is generally well maintained.
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Significant improvement in co-morbidities.
© 2000 University of Pennsylvania School of Medicine
Surgical Treatment of Obesity
Vertical Banded Gastroplasty (VBG)
Staple Line
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Formation of small
proximal gastric pouch.
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Restricts amount of food
without bypassing the gut.
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Delays gastric emptying.
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Creates feeling of early
satiety.
Pouch
Band
Fundus
© 2000 University of Pennsylvania School of Medicine
Surgical Treatment of Obesity
Gastric Bypass
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Formation of 20-30 ml
proximal gastric pouch.
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Delays gastric emptying.
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Interferes with absorption
of nutrients.

May induce dumping
syndrome after high
carbohydrate meal.
Staple Line
Pouch
Fundus
Jejunum
© 2000 University of Pennsylvania School of Medicine
Treatment of Obesity
Popular Weight Loss Diets
 Low-calorie diets

Calorie deficit allows for 1 to 2 pound weight loss/week
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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.
© 2000 University of Pennsylvania School of Medicine
Treatment of Obesity
Popular Weight Loss Diets
 Low-calorie diets

Weight Watchers

Jenny Craig
 Low-carbohydrate diets

Dr. Atkins’ New Diet Revolution

The Zone

Sugar Busters
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine
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
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine
Sugar Busters
Drs. 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).
© 2000 University of Pennsylvania School of Medicine
Improving Weight-loss
Maintenance
 Continued care
 Exercise
 Pharmacotherapy
 Other
© 2000 University of Pennsylvania School of Medicine
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
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine
What Is A Reasonable Weight Loss ?
Patients’ Expectations and Evaluations of
Obesity Treatment and Outcome
 Study design
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60 obese women, age 40 + 8.7 yrs.
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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.
© 2000 University of Pennsylvania School of Medicine
Results
Defined Weights
% Reduction
Dream
38%
Happy
31%
Acceptable
25%
Disappointed
17%
Foster GD, et al. J Consult Clin Psychol 1997;65:79-85.
© 2000 University of Pennsylvania School of Medicine
Percent Achieving Defined
Weight at Week 48 (n=45)
Happy
9%
Dream = 0%
Acceptable
24%
Weight loss:
16.3 ± 7.2 kg
Disappointed
20%
Did not Reach
Disappointed
Weight 47%
Foster GD, et al. J Consult Clin Psychol 1997;65:79-85.
© 2000 University of Pennsylvania School of Medicine
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.
© 2000 University of Pennsylvania School of Medicine