Presentation on theme: "Weight Management Strategies: Medical and Nutritional Therapy"— Presentation transcript:
1Weight Management Strategies: Medical and Nutritional Therapy
2What is Successful Weight Loss? Common definition: Lose at least 10% of starting weight and keep it off at least one year.
3What 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, 1997accessed
6Who Should Consider A Weight Management Intervention? Persons with a BMI of >30Persons with a BMI between OR a high-risk waist circumference, and two or more risk factorsPersons who are ready to changeNHLBI Obesity Education Initiative. The Practical Guide Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI , 2000.
7Obesity-Associated Risk Factors: High Absolute Risk Established coronary heart diseaseOther atherosclerotic diseasesType 2 diabetesSleep apneaNHLBI Obesity Education Initiative. The Practical Guide Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI , 2000.
8Obesity-Associated Risk Factors: 3 or More = ↑ Risk HypertensionCigarette smokingHigh low-density lipoprotein cholesterolLow high-density lipoprotein cholesterolImpaired fasting glucoseFamily history of early cardiovascular diseaseAge (male ≥ 45 years, female ≥ 55 years)NHLBI Obesity Education Initiative. The Practical Guide Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI , 2000.
9Other Obesity-Associated Risk Factors OsteoarthritisGallstonesStress incontinenceGynecological abnormalitiesNHLBI Obesity Education Initiative. The Practical Guide to Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI , 2000.
10How Much and How Fast?NIH guidelines recommend a weight loss of .5 to 1 pound/week for persons with a BMI of and 1-2 pounds a week for those with a BMI>35 kg/m2Allow 6 months to achieve 10% weight lossAfter 6 months, focus should shift to weight maintenance for 6 monthsFollowing this, weight loss efforts may resume (NIH, 1998)
11Weight Loss GoalsR.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, ImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
12Rates of Weight Loss Vary Men will lose weight faster than women of similar size, due to higher LBM and RMRA heavier person (who has higher energy needs) will lose weight faster than a smaller person on the same caloric regimen
13Modest 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 Feb 7;346(6):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
14Modest Weight Loss and Health: Hypertension 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)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.
15Modest Weight Loss and Health: Hyperlipidemia The ATP-III guidelines recommend a 10% weight loss in overweight persons with hyperlipidemia.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:
16Modest 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:A 5% weight loss can decrease FBG, insulin, A1C concentrations and medication requirements. Wing RR et al. Arch Intern Med 1987;147:
17Setting Weight Management Goals Many severely overweight persons have unrealistic expectations in setting weight loss goals (Blackburn, 1998)Even modest weight loss may produce significant improvements in healthFor some persons (especially those with BMI of ) weight maintenance may be a goal
18Evaluation of Body WtR.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, ImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
19Estimation of Energy Needs 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, ConditionalAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
20Readiness to Change: A Brief Assessment 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?
21Readiness to Change: A Brief Assessment 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?
22NIH Recommended Interventions Dietary therapyPhysical activityBehavior therapyPharmacotherapyBariatric surgery
23Comprehensive Wt Mgt Program 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, ImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
25Optimal Length of Wt Mgt Therapy 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, ImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
26Goals of Weight Management (NIH) Achievement of healthy body weight (or close to desired BMI)Select a realistic goal—no more than 1 to 1.5 lb/weekPrevent loss of LBM, especially from heart and brainSupport psychosocial factors
27Reduced Calorie DietsR.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, ImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
28Balanced Energy-Restricted Diet Is the most widely-prescribed method of weight reductionShould be nutritionally adequate except for energyEnergy level varies with individual’s size, sex, and activity, ranging from 800 kcals to 1500 kcals (NIH, 1998)
29Balanced Energy-Restricted Diet Should be relatively high in carbohydrate (50-55% of total kcals)CHO sources should be fruits, vegetables, whole grainsInclude generous protein (15-25% of kcals) for increased satiety and to assure adequate supplyFat < 30% of kcalsIncreased fiber to improve satiety (NIH, 1998)
30Balanced Energy-Restricted Diet Alcohol and high-sugar foods should be limited to limit excess energyUse of non-nutritive sweeteners and fat replacements may improve the palatability of the dietVitamins and mineral supplements may be needed in programs that provide <1200 kcals for women or 1800 kcals for men (NIH, 1998)
31Exchange System DietsAllow flexibility in making food choices while limiting total caloric intakeProvides framework for healthy balance of nutrientsMay be too complex or restrictive for some clients
32Nutrition EducationR.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, ImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
33Eating Frequency and Patterns 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, ImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
34Portion ControlR.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, ImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
35Meal ReplacementsR.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, ConditionalAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
36Low Glycemic Index Diets 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, ImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
37Lowfat Dairy FoodsR.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, ImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
38Low Carbohydrate Diets 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, ConditionalAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
39Very Low Calorie Diets (VLCD) Diets providing kcals/dayHypocaloric but relatively rich in protein ( g/kg/day)Designed to include adequate vitamins, minerals, electrolytes, and EFAsCompletely replace usual meal intakeUsually given for weeksUsually reserved for those with BMI>30; or with risk factorsNHLBI, 2000
40Protein Sparing Modified Fast (PSMF) Uses real foodContains 1.5 g protein/kg IBW as lean meat, fish and poultryMay include low-carbohydrate vegetablesOnly fat is that present in the protein sourcesNIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000
41Commercial VLCD Liquid Diets Contain g of protein, g CHO, small amount of fatProvides kcalsPatients lose 20 kg in 12 to 16 weeksNIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000
42VLCDs 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 electrolytesBut VLCDs may be a moreeffective method of weightloss for some(Anderson et al Am J Clin Nutr 74;579:2001)
43Dietary Therapy: NIH Guidelines Very low calorie diets (VLCDs) should not be used routinely for weight loss therapy because they require special monitoring and supplementationLCDs may be just as effectiveNIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000
45Behavioral Therapy: NIH Guidelines Self-monitoringStress managementStimulus controlProblem-solvingContingency managementCognitive restructuringSocial support
46Behavior Therapy in Wt Mgt 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, ImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
47Self Monitoring Records of place and time of food intake Accompanying thoughts and feelingsHelps identify the physical and emotional settings in which eating occursProvides feedback on progress and puts responsibility on the patient
48Problem Solving Process for defining the eating or weight problem Generating possible solutions; evaluating the solutions, choosing the best oneTrialing the new behavior, evaluating outcome and generating alternatives
49Stimulus Control Modification of The settings or the chain of events that precede eatingThe kinds of foods consumedThe consequences of eatingBecome mindful of satiety cuesPut fork down between bitesPausing during meals
50Cognitive Restructuring Teaches patients to identify, challenge, and correct negative thoughtsPositive self-talk
51Behavior Modification Most effective in mildly obese (20-40% overweight)Patients can maintain losses of poundsLonger programs more successfulMany patients regain the weight they lost over timeNIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000
53Pharmacological Therapy NIH Guidelines Should be used only in the context of a program that includes lifestyle changesIf lifestyle changes do not promote weight loss after 6 months, drugs should be consideredLimited to those with BMI ≥30; or ≥27 with risk factorsNIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000
54Wt Loss MedicationsR.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 FDA-approved 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, ImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
55Catecholaminergic Drugs Appetite suppressantsAct on the brain, increasing the availability of norepinephrineSchedule II anorexic agentsHigh potential for abuseInclude amphetamine, phenmetrazine HClNot recommended for weight managementSchedule III agentsSome potential for abuseInclude benzphetamine HCl, phendimetrazine tartrateSee Table 21-5 Krause 12th edition, p. 551
56Catecholaminergic Drugs Schedule IV agentsIncludes diethypropion HCl, manzindol HCl, phentermine HCl, phentermine resinLow potential for abuseCan raise blood pressure, so prescribed with caution in patients with hypertensionNIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000
57Serotonin Reuptake Inhibitors Includes sibutramine (Meridia)Inhibits the reuptake of serotonin and norepinephrineInitially developed to treat depressionUse caution in hypertension, CHD, arrhythmias, CHFNIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000
58Orlistat (Xenical) Lipase inhibitor Acts directly on the gastrointestinal tract to inhibit fat absorptionAssociated with reduced LDL-C and increased HDL; improved glycemic control, reduced blood pressureSome concern about fat soluble vitaminsSide effects: oily spotting, fecal urgency, flatus with dischargeNIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000
59FDA Approves Reduced Dose of Orlistat for Over the Counter Over the counter dose of orlistat, a lipase inhibitorHalf the dose of prescription form (Xenical)The only FDA-approved over the counter wt mgt drugAvailable summer 2007
60Serotoninergic Agents Increase serotonin levels in the brainFenfluramine hydrochloride and dexfenfluramine HCl (Fen-Phen) were removed from the market in 1997 due to association with heart valve disease and pulmonary hypertension
61Pharmacological Obesity Treatments Weight loss of about 1 lb/week can be expectedMost weight loss will occur within the first 6 months of therapySignificant weight maintenance as long as the drug treatment is continuedMost patients regain weight if medication is stopped
62Pharmacological Obesity Treatments Weight-loss medications lead to an additional weight loss of 5 to 22 pounds more than with non-drug obesity treatmentsTwo to 20 kg total loss, usually during first 6 months of treatmentWhen drugs are discontinued, weight regain occurs
64Physical ActivityR.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, ImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
65Physical Activity: NIH Guidelines Physical activity increases energy expenditure and plays an integral role in weight maintenanceReduces the risk of heart disease more than weight loss aloneReduces body fat, prevents decrease in muscle mass during weight lossAll 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
66Role of Physical Activity in Weight Management 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 regainPhysical activity also is beneficial in reducing risk for heart disease and diabetes beyond the effect of weight loss
67Role of Physical Activity in Weight Management Exercise helps balance the loss of LBM and reduction in RMR caused by hypocaloric dietsA combination of aerobic exercise and resistance training is recommendedEven when weight loss does not occur, loss of body fat often doesMay require 2 months to see loss of weight through exercise
68U.S. Dietary Guidelines 2005Suggest 60 minutes of moderate-vigorous activity on most days of the week to prevent weight gain in adulthoodTo sustain weight loss in adulthood: at least minutes of daily moderate-intensity physical activityAchieve physical fitness by including cardiovascular conditioning, stretching exercises for flexibility, and resistance exercises or calisthenics for muscle strength and endurance.
69Role of Physical Activity in Weight Management Other Benefits:—Improved sense of well-being—Relief of boredom—Sense of control—Relief from depression
70Bariatric SurgeryR 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, ImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07
71Bariatric Surgery: NIH Guidelines Option for well-informed and motivated patients with clinically severe obesity (BMI≥40 or BMI ≥35 with serious co-morbid conditionsNIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000
72Candidates for Bariatric Surgery BMI of 40 or more—about 100 pounds overweight for men and 80 pounds for womenBMI between 35 and 39.9 and a serious obesity-related health problem such as type 2 diabetes, heart disease, or severe sleep apneaWillingness to make associated lifestyle changes
73Bariatric Surgery Options RestrictiveMalabsorptiveCombination restrictive/malabsorptive
74Restrictive Procedures 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 stomachVertical banded gastroplasty. VBG uses both a band and staples to create a small stomach pouch (not often used today)
76Diet After SurgeryAfter restrictive surgeries, patients can only eat ½ cup to 1 cup of food at a timeFoods often must be soft and chewed thoroughlyPatients who eat too fast or the wrong kinds of food may have vomiting
77Restrictive Procedures: Advantages Don’t interfere with the normal digestive processEasier to perform and generally safer than malabsorptive surgeriesAGB often done laparoscopicallyCan be reversed if necessary
78Restrictive Procedures: Disadvantages Generally results in less weight lossPatients generally lose about half of their excess body weight in the first year after restrictive proceduresOnly 20% keep weight off over 10 years, though there is evidence that AGB is more effective than VBG
79Restrictive/Malabsorptive Procedures Roux-en-Y gastric bypass (RGB) is the most commonThe 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.
81Restrictive/Malabsorptive Procedures: Advantages Patients lose weight quickly and continue to lose months after the procedureWith RGB, many patients maintain a weight loss of 60 to 70 percent of their excess weight for 10 years or more
82Restrictive/Malabsorptive Procedures: Disadvantages More difficult to performMore likely to result in long-term nutritional deficiencies (calcium, iron)Greater risk of dumping syndromeIncreased likelihood of complications including hernia (decreased with laparoscopic procedures)
83Weight Management—Children Goals: Weight maintenance or slowing of gainsGrow into weightIf severely obese, lose no more than 1 lb monthly to reach desired adult weight for height
84Weight 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
85Weight Management in Children Overweight children should try to achieve weight maintenance or slowing of the rate of weight gain, not weight lossDepends on age and degree of overweightOnce adult height is achieved, weight loss is necessary to improve health
86SummaryEven 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