Transcript Weight Management Strategies: Medical and Nutritional Therapy

Weight Management
Strategies: Medical and
Nutritional Therapy
What is Successful
Weight Loss?

Common definition: Lose at least 10%
of starting weight and keep it off at
least one year.
What is the Goal of
Obesity Treatment?

Specifically, the goal of obesity
treatment should be refocused from
weight loss alone, which is often
aimed at appearance, to weight
management, achieving the best
weight possible in the context of
overall health. –FTC Panel, Commercial
Weight Loss Products and Programs
What Consumers Stand To Gain and Lose,
1997
http://www.ftc.gov/os/1998/03/weightlo.rpt.htm accessed 3-13-06
Who Should Consider A Weight
Management Intervention?
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Persons with a BMI of >30
Persons with a BMI between 25-29.9
OR a high-risk waist circumference,
and two or more risk factors
Persons 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
Factors: High Absolute Risk
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Established coronary heart disease
Other atherosclerotic diseases
Type 2 diabetes
Sleep 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
Factors: 3 or More = ↑ Risk
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Hypertension
Cigarette smoking
High low-density lipoprotein cholesterol
Low high-density lipoprotein cholesterol
Impaired fasting glucose
Family history of early cardiovascular
disease
Age (male ≥ 45 years, female ≥ 55 years)

NHLBI Obesity Education Initiative. The Practical Guide Identification,
Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI
00-4084, 2000.
Other Obesity-Associated
Risk Factors
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Osteoarthritis
Gallstones
Stress incontinence
Gynecological 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 Fast?
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NIH guidelines recommend a weight loss of
.5 to 1 pound/week for persons with a BMI
of 27-35 and 1-2 pounds a week for those
with a BMI>35 kg/m2
Allow 6 months to achieve 10% weight loss
After 6 months, focus should shift to weight
maintenance for 6 months
Following this, weight loss efforts may
resume (NIH, 1998)
Weight Loss Goals


R.4.0. Individualized goals of weight loss
therapy should be to reduce body weight at
an optimal rate of 1-2 lbs per week for the
first 6 months and to achieve an initial
weight loss goal of up to 10% from
baseline.
These goals are realistic, achievable, and
sustainable.
Strong, Imperative
American Dietetic Association Evidence Analysis Library Adult
Wt Mgt Guidelines, accessed 2/07
Rates of Weight Loss Vary
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Men will lose weight faster than
women of similar size, due to higher
LBM and RMR
A heavier person (who has higher
energy needs) will lose weight faster
than a smaller person on the same
caloric regimen
Modest Weight Loss and
Health: Diabetes Prevention

A 7% weight loss (mean 15 pounds)
through diet and exercise in high risk
individuals was associated with a 58%
reduction of diabetes incidence in the
Diabetes Prevention Program DPP Research
Group. N Engl J Med. 2002 Feb 7;346(6):393-403.
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An average 7.7 pound weight loss was
associated with a 58% reduction in diabetes
incidence in high risk individuals in the
Finnish Diabetes Prevention study. FDPS Group.
N Engl J Med 344:1343–1350, 2001
Modest Weight Loss and
Health: Hypertension
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Weight loss of as little as 4.5 kg (10
pounds) will improve or prevent
hypertension in a large segment of
overweight persons. Seventh Report of the Joint
National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7)
http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf
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Clinically significant long-term reductions in
blood pressure and reduced risk for
hypertension can be achieved with modest
weight loss and increased physical activity.
American Dietetic Association Evidence Analysis Library,
Hypertension and hyperlipidemia.
http://www.adaevidencelibrary.org/
Modest Weight Loss and
Health: Hyperlipidemia
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The ATP-III guidelines recommend a 10%
weight loss in overweight persons with
hyperlipidemia.
http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf
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A weight loss of ≥2.25 kg was associated
with a 40-50% reduction in cardiovascular
risk factors in the Framingham Offspring
Study (BP, triglyceride, TC, FBS, HDL) Karason K
et al. Int J Obes Relat Metab Disord 1999;23:948-56.
Modest Weight Loss and
Health: Diabetes

Calorie restriction and weight loss improves
insulin sensitivity and glycemic control in
obese patients with Type 2 diabetes. Henry RR
et al. J Clin Endocrinol Metab 1985;61:917-25; Kelly DE et al. J Clin
Endocrinol MEtab 1993;77:1287-93.
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A 5% weight loss can decrease FBG, insulin,
A1C concentrations and medication
requirements. Wing RR et al. Arch Intern Med
1987;147:1749-53.
Setting Weight
Management Goals
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Many severely overweight persons
have unrealistic expectations in setting
weight loss goals (Blackburn, 1998)
Even modest weight loss may produce
significant improvements in health
For some persons (especially those
with BMI of 25-29.9) weight
maintenance may be a goal
Evaluation of Body Wt
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R.1.1 Body mass index (BMI) and waist
circumference should be used to classify
overweight and obesity, estimate risk for
disease, and to identify treatment options.
BMI and waist circumference are highly
correlated to obesity or fat mass and risk of
other diseases (NHLBI report). Fair,
Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt
Guidelines, accessed 2/07
Estimation of Energy
Needs
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R.5.0 Estimated energy needs should be
based on RMR. If possible, RMR should be
measured (e.g., indirect calorimetry).
If RMR cannot be measured, then the
Mifflin-St. Jeor equation using actual
weight is the most accurate for estimating
RMR for overweight and obese individuals.
Strong, Conditional
American Dietetic Association Evidence Analysis Library Adult Wt Mgt
Guidelines, accessed 2/07
Readiness to Change: A
Brief Assessment
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Has the individual sought weight loss
on his/her own initiative?
What has led the patient to seek
weight loss now?
What are the patient’s stress level and
mood?
Does the individual have an eating
disorder?
Readiness to Change: A
Brief Assessment
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Does the individual understand the
requirements of treatment and believe
that he/she can fulfill them?
How much weight does the patient
expect to lose?
NIH Recommended
Interventions
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Dietary therapy
Physical activity
Behavior therapy
Pharmacotherapy
Bariatric surgery
Comprehensive Wt Mgt
Program
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R.2.0 Weight loss and weight
maintenance therapy should be based
on a comprehensive weight
management program including diet,
physical activity, and behavior therapy.
The combination therapy is more
successful than using any one
intervention alone. Strong,
Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt
Guidelines, accessed 2/07
Dietary Interventions
Optimal Length of Wt Mgt
Therapy
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R.3.0. Medical Nutrition Therapy for weight
loss should last at least 6 months or until
weight loss goals are achieved, with
implementation of a weight maintenance
program after that time.
Greater frequency of contacts between the
patient and practitioner may lead to more
successful weight loss and maintenance.
Strong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt
Mgt Guidelines, accessed 2/07
Goals of Weight
Management (NIH)
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Achievement of healthy body weight
(or close to desired BMI)
Select a realistic goal—no more than 1
to 1.5 lb/week
Prevent loss of LBM, especially from
heart and brain
Support psychosocial factors
Reduced Calorie
Diets
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R.6.0 An individualized reduced calorie diet
is the basis of the dietary component of a
comprehensive weight management
program.
Reducing dietary fat and/or carbohydrates is
a practical way to create a caloric deficit of
500 – 1000 kcals below estimated energy
needs and should result in a weight loss of 1
– 2 lbs per week. Strong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt
Mgt Guidelines, accessed 2/07
Balanced EnergyRestricted Diet
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Is the most widely-prescribed method
of weight reduction
Should be nutritionally adequate
except for energy
Energy level varies with individual’s
size, sex, and activity, ranging from
800 kcals to 1500 kcals (NIH, 1998)
Balanced EnergyRestricted Diet
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Should be relatively high in carbohydrate
(50-55% of total kcals)
– CHO sources should be fruits, vegetables, whole
grains
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Include generous protein (15-25% of kcals)
for increased satiety and to assure adequate
supply
Fat < 30% of kcals
Increased fiber to improve satiety (NIH,
1998)
Balanced EnergyRestricted Diet
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Alcohol and high-sugar foods should
be limited to limit excess energy
Use of non-nutritive sweeteners and
fat replacements may improve the
palatability of the diet
Vitamins and mineral supplements
may be needed in programs that
provide <1200 kcals for women or
1800 kcals for men (NIH, 1998)
Exchange System Diets
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Allow flexibility in making
food choices while limiting
total caloric intake
Provides framework for
healthy balance of nutrients
May be too complex or
restrictive for some clients
Nutrition Education
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R.10.0 Nutrition education should be
individualized and included as part of the
diet component of a comprehensive weight
management program.
Short term studies show that nutrition
education (e.g. reading nutrition labels,
recipe modification, cooking classes)
increases knowledge and may lead to
improved food choices. Fair, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt
Mgt Guidelines, accessed 2/07
Eating Frequency and
Patterns
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R.7.0 Total caloric intake should be
distributed throughout the day, with the
consumption of 4 to 5 meals/snacks per day
including breakfast.
Consumption of greater energy intake
during the day may be preferable to evening
consumption. Fair, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt
Mgt Guidelines, accessed 2/07
Portion Control
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R.8.0 Portion control should be
included as part of a comprehensive
weight management program. Portion
control at meals and snacks results in
reduced energy intake and weight
loss. Fair, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt
Mgt Guidelines, accessed 2/07
Meal Replacements
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R.9.0 For people who have difficulty with self
selection and/or portion control, meal replacements
(e.g., liquid meals, meal bars, calorie-controlled
packaged meals) may be used as part of the diet
component of a comprehensive weight
management program.
Substituting one or two daily meals or snacks with
meal replacements is a successful weight loss and
weight maintenance strategy. Strong, Conditional
American Dietetic Association Evidence Analysis Library Adult Wt
Mgt Guidelines, accessed 2/07
Low Glycemic Index Diets
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R.11a A low glycemic index diet is not
recommended for weight loss or
weight maintenance as part of a
comprehensive weight management
program, since it has not been shown
to be effective in these areas. Strong,
Imperative
American Dietetic Association Evidence Analysis Library Adult Wt
Mgt Guidelines, accessed 2/07
Lowfat Dairy Foods
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R.11b. In order to meet current nutritional
recommendations, incorporate 3-4 servings
of low fat dairy foods a day as part of the
diet component of a comprehensive weight
management program.
Research suggests that calcium intake lower
than recommended levels is associated with
increased body weight. However, the effect
of dairy and/or calcium at or above
recommended levels on weight
management is unclear. Fair, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt
Guidelines, accessed 2/07
Low Carbohydrate Diets
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R.11c Having patients focus on reducing
carbohydrates rather than reducing calories and/or
fat may be a short term strategy for some
individuals.
Research indicates that focusing on reducing
carbohydrate intake (<35% of kcals from
carbohydrates) results in reduced energy intake.
Consumption of a low-carbohydrate diet is
associated with a greater weight and fat loss than
traditional reduced calorie diets during the first 6
months, but these differences are not significant
after 1 year. Fair, Conditional
American Dietetic Association Evidence Analysis Library Adult Wt
Mgt Guidelines, accessed 2/07
Very Low Calorie Diets
(VLCD)
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Diets providing 200-800 kcals/day
Hypocaloric but relatively rich in protein (.81.5 g/kg/day)
Designed to include adequate vitamins,
minerals, electrolytes, and EFAs
Completely replace usual meal intake
Usually given for 12-16 weeks
Usually reserved for those with BMI>30; or
27-30 with risk factors
NHLBI, 2000
Protein Sparing Modified
Fast (PSMF)
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Uses real food
Contains 1.5 g protein/kg IBW as lean
meat, fish and poultry
May include low-carbohydrate
vegetables
Only fat is that present in the protein
sources
NIH NHLBI The practical guide. Identification, evaluation, and
treatment of overweight and obesity in adults. NHLBI, 2000
Commercial VLCD Liquid
Diets
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Contain 33-70 g of
protein, 30-45 g
CHO, small amount
of fat
Provides 400-800
kcals
Patients lose 20 kg
in 12 to 16 weeks
NIH NHLBI The practical guide.
Identification, evaluation, and treatment of
overweight and obesity in adults. NHLBI,
2000
VLCDs
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Cardiac complications a concern
Risks include potassium loss as well as
body protein (higher in the less obese)
Requires close medical supervision and
monitoring of serum electrolytes
But VLCDs may be a more
effective method of weight
loss for some
(Anderson et al Am J Clin Nutr 74;579:2001)
Dietary Therapy: NIH
Guidelines
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Very low calorie diets (VLCDs) should
not be used routinely for weight loss
therapy because they require special
monitoring and supplementation
LCDs may be just as effective
NIH NHLBI The practical guide. Identification, evaluation, and
treatment of overweight and obesity in adults. NHLBI, 2000
Behavioral Therapy in
Weight Management
Behavioral Therapy: NIH
Guidelines
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Self-monitoring
Stress management
Stimulus control
Problem-solving
Contingency management
Cognitive restructuring
Social support
Behavior Therapy in Wt
Mgt
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R.13.0 A comprehensive weight management
program should make maximum use of multiple
strategies for behavior therapy (e.g. self
monitoring, stress management, stimulus control,
problem solving, contingency management,
cognitive restructuring, and social support).
Behavior therapy in addition to diet and physical
activity leads to additional weight loss. Continued
behavioral interventions may be necessary to
prevent a return to baseline weight. Strong,
Imperative
American Dietetic Association Evidence Analysis Library Adult Wt
Mgt Guidelines, accessed 2/07
Self Monitoring
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Records of place and time of food
intake
Accompanying thoughts and feelings
Helps identify the physical and
emotional settings in which eating
occurs
Provides feedback on progress and
puts responsibility on the patient
Problem Solving
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Process for defining the eating or
weight problem
Generating possible solutions;
evaluating the solutions, choosing the
best one
Trialing the new behavior, evaluating
outcome and generating alternatives
Stimulus Control
Modification of
 The settings or the chain of events
that precede eating
 The kinds of foods consumed
 The consequences of eating
– Become mindful of satiety cues
– Put fork down between bites
– Pausing during meals
Cognitive Restructuring
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Teaches patients to identify, challenge,
and correct negative thoughts
Positive self-talk
Behavior Modification
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Most effective in mildly obese (20-40%
overweight)
Patients can maintain losses of 20-25
pounds
Longer programs more successful
Many patients regain the weight they
lost over time
NIH NHLBI The practical guide. Identification, evaluation, and
treatment of overweight and obesity in adults. NHLBI, 2000
Weight Loss Medications
Pharmacological Therapy
NIH Guidelines
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Should be used only in the context of
a program that includes lifestyle
changes
If lifestyle changes do not promote
weight loss after 6 months, drugs
should be considered
Limited to those with BMI ≥30; or ≥27
with risk factors
NIH NHLBI The practical guide. Identification, evaluation, and
treatment of overweight and obesity in adults. NHLBI, 2000
Wt Loss Medications
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R.14.0 FDA-approved weight loss medications may
be part of a comprehensive weight management
program.
Dietitians should collaborate with other members of
the health care team regarding the use of FDAapproved weight loss medications for people who
meet the NHLBI criteria.
Research indicates that pharmacotherapy may
enhance weight loss in some overweight and obese
adults. Strong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt
Guidelines, accessed 2/07
Catecholaminergic Drugs
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Appetite suppressants
Act on the brain, increasing the availability of
norepinephrine
Schedule II anorexic agents
– High potential for abuse
– Include amphetamine, phenmetrazine HCl
– Not recommended for weight management

Schedule III agents
– Some potential for abuse
– Include benzphetamine HCl, phendimetrazine
tartrate
See Table 21-5 Krause 12th edition, p. 551
Catecholaminergic Drugs
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Schedule IV agents
– Includes diethypropion HCl, manzindol
HCl, phentermine HCl, phentermine resin
– Low potential for abuse
– Can raise blood pressure, so prescribed
with caution in patients with hypertension
NIH NHLBI The practical guide. Identification, evaluation, and
treatment of overweight and obesity in adults. NHLBI, 2000
Serotonin Reuptake
Inhibitors
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Includes sibutramine (Meridia)
Inhibits the reuptake of serotonin and
norepinephrine
Initially developed to treat depression
Use caution in hypertension, CHD,
arrhythmias, CHF
NIH NHLBI The practical guide. Identification, evaluation, and
treatment of overweight and obesity in adults. NHLBI, 2000
Orlistat (Xenical)
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Lipase inhibitor
Acts directly on the gastrointestinal tract to
inhibit fat absorption
Associated with reduced LDL-C and
increased HDL; improved glycemic control,
reduced blood pressure
Some concern about fat soluble vitamins
Side effects: oily spotting, fecal urgency,
flatus with discharge
NIH NHLBI The practical guide. Identification, evaluation, and
treatment of overweight and obesity in adults. NHLBI, 2000
FDA Approves Reduced Dose of
Orlistat for Over the Counter
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Over the counter dose
of orlistat, a lipase
inhibitor
Half the dose of
prescription form
(Xenical)
The only FDA-approved
over the counter wt
mgt drug
Available summer 2007
Serotoninergic Agents
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Increase serotonin levels in the brain
Fenfluramine hydrochloride and
dexfenfluramine HCl (Fen-Phen) were
removed from the market in 1997 due
to association with heart valve disease
and pulmonary hypertension
Pharmacological Obesity
Treatments
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Weight loss of about 1 lb/week can be
expected
Most weight loss will occur within the
first 6 months of therapy
Significant weight maintenance as long
as the drug treatment is continued
Most patients regain weight if
medication is stopped
Pharmacological Obesity
Treatments
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Weight-loss medications lead to an
additional weight loss of 5 to 22
pounds more than with non-drug
obesity treatments
Two to 20 kg total loss, usually during
first 6 months of treatment
When drugs are discontinued, weight
regain occurs
Physical Activity and
Weight Management
Physical Activity
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R.12.0 Physical activity should be part of a
comprehensive weight management program.
Physical activity level should be assessed and
individualized long-term goals established to
accumulate at least 30 minutes or more of
moderate intensity physical activity on most, and
preferably, all days of the week, unless medically
contraindicated.
Physical activity contributes to weight loss, may
decrease abdominal fat, and may help with
maintenance of weight loss. Strong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt
Mgt Guidelines, accessed 2/07
Physical Activity: NIH
Guidelines
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Physical activity increases energy
expenditure and plays an integral role in
weight maintenance
Reduces the risk of heart disease more than
weight loss alone
Reduces body fat, prevents decrease in
muscle mass during weight loss
All adults: goal of 30 minutes or more of
moderate-intensity physical activity on most
and preferably all days.
NIH NHLBI The practical guide. Identification, evaluation, and
treatment of overweight and obesity in adults. NHLBI, 2000
Role of Physical Activity
in Weight Management
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Physical activity usually will not lead to
a greater weight loss over diet alone in
a 6-month period (NIH, 2000)
Physical activity is most helpful in
preventing weight regain
Physical activity also is beneficial in
reducing risk for heart disease and
diabetes beyond the effect of weight
loss
Role of Physical Activity
in Weight Management
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Exercise helps balance the loss of LBM
and reduction in RMR caused by
hypocaloric diets
A combination of aerobic exercise and
resistance training is recommended
Even when weight loss does not occur,
loss of body fat often does
May require 2 months to see loss of
weight through exercise
U.S. Dietary Guidelines
2005
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Suggest 60 minutes of moderate-vigorous
activity on most days of the week to prevent
weight gain in adulthood
To sustain weight loss in adulthood: at least
60-90 minutes of daily moderate-intensity
physical activity
Achieve physical fitness by including
cardiovascular conditioning, stretching
exercises for flexibility, and resistance
exercises or calisthenics for muscle strength
and endurance.
http://www.health.gov/dietaryguidelines/dga2005/recommendati
ons.htm
Role of Physical Activity
in Weight Management
Other Benefits:
—Improved sense of well-being
—Relief of boredom
—Sense of control
—Relief from depression
Bariatric Surgery
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R.15.0. Dietitians should collaborate with
other members of the health care team
regarding the appropriateness of bariatric
surgery for people who have not achieved
weight loss goals with less invasive weight
loss methods and who meet the NHLBI
criteria.
Separate ADA evidence based guidelines are
being developed on nutrition care in
bariatric surgery. Strong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt
Mgt Guidelines, accessed 2/07
Bariatric Surgery: NIH
Guidelines

Option for well-informed and
motivated patients with clinically
severe obesity (BMI≥40 or BMI ≥35
with serious co-morbid conditions
NIH NHLBI The practical guide. Identification, evaluation, and
treatment of overweight and obesity in adults. NHLBI, 2000
Candidates for Bariatric
Surgery
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BMI of 40 or more—about 100 pounds
overweight for men and 80 pounds for
women
BMI between 35 and 39.9 and a serious
obesity-related health problem such as type
2 diabetes, heart disease, or severe sleep
apnea
Willingness to make associated lifestyle
changes
Bariatric Surgery Options

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Restrictive
Malabsorptive
Combination restrictive/malabsorptive
Restrictive Procedures
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Adjustable gastric banding (AGB) a
hollow band made of silicone rubber is
placed around the stomach near its upper
end, creating a small pouch and a narrow
passage into the rest of the stomach
Vertical banded gastroplasty. VBG uses
both a band and staples to create a small
stomach pouch (not often used today)
Restrictive Surgery:
Adjustable Gastric Band
Diet After Surgery

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After restrictive surgeries, patients can
only eat ½ cup to 1 cup of food at a
time
Foods often must be soft and chewed
thoroughly
Patients who eat too fast or the wrong
kinds of food may have vomiting
Restrictive Procedures:
Advantages

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Don’t interfere with the normal
digestive process
Easier to perform and generally safer
than malabsorptive surgeries
AGB often done laparoscopically
Can be reversed if necessary
Restrictive Procedures:
Disadvantages
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Generally results in less weight loss
Patients generally lose about half of
their excess body weight in the first
year after restrictive procedures
Only 20% keep weight off over 10
years, though there is evidence that
AGB is more effective than VBG
Restrictive/Malabsorptive
Procedures

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Roux-en-Y gastric bypass (RGB) is the
most common
The surgeon creates a small stomach pouch
to restrict food intake. Next, a Y-shaped
section of the small intestine is attached to
the pouch to allow food to bypass the lower
stomach, the duodenum and the first
portion of the jejunum.
This reduces the amount of calories and
nutrients the body absorbs.
Restrictive/Malabsorptive:
Roux en Y
Restrictive/Malabsorptive
Procedures: Advantages

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Patients lose weight quickly and
continue to lose 18-24 months after
the procedure
With RGB, many patients maintain a
weight loss of 60 to 70 percent of their
excess weight for 10 years or more
Restrictive/Malabsorptive
Procedures: Disadvantages
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More difficult to perform
More likely to result in long-term
nutritional deficiencies (calcium, iron)
Greater risk of dumping syndrome
Increased likelihood of complications
including hernia (decreased with
laparoscopic procedures)
Weight Management—
Children



Goals: Weight maintenance or slowing
of gains
Grow into weight
If severely obese, lose no more than 1
lb monthly to reach desired adult
weight for height
Weight Management in
Children
At risk at BMI 85% to 95%ile; obese
at 95%
 Review parents’ history—height,
weight, etc.
 Weight management in children is a
family affair

Weight Management in
Children

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Overweight children should try to
achieve weight maintenance or
slowing of the rate of weight gain, not
weight loss
Depends on age and degree of
overweight
Once adult height is achieved, weight
loss is necessary to improve health
Summary


Even modest weight loss can
produce improvements in overall
health in persons who are
overweight (lipids, BG, insulin,
blood pressure)
Most persons will need sustained,
long-term lifestyle interventions to
achieve significant weight loss