Treatment of Obesity Pennington Biomedical Research Center Division

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? 2009 2

Steps in determining treatment § Determine BMI. § Assess complications and risk factors 2009 3

Steps in determining treatment § Determine BMI-related health risk § Determine weight reduction exclusions § Mental illness § Unstable medical condition § Some medications § Temporary § Pregnancy or lactation 2009 4

Steps in determining treatment § Possible exclusions § Osteoporosis § BMI in minimal or no-risk category § History of mental illness § Medications § Permanent exclusions § Anorexia nervosa § Terminal illness § Assess patient readiness 2009 5

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 2009 6

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. 2009 7

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. 2009 8

Dieting with the Exchange List Food is broken down into 6 categories: Starch/Bread Meat Vegetables Fruit Milk Fat 2009 9

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. 2009 10

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 4 5 4 7 5 7 6 8 6 9 6 10 6 11 2 3 3 3 2 4 3 3 2 2 3 3 - 2 4 3 - 3 4 4 - 2 2 2 3 11

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 2009 2 Fruits 2 Breads 1 Meat 2 Fat 1 Milk Free Food 12

Example of daily exchange diet: 1800 Kcals daily LUNCH ½ c tuna 2 slices whole wheat bread ½ c tomato slices Lettuce/cucumber salad Yield 1 c sliced peaches s 1 tsp margarine Tea with lemon 2009 2 Meat 2 Bread 1 Vegetable Raw Vegetable 2 Fruit 2 Fat Free Foods 13

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 2009 3 meat 1 Bread 1 Vegetable Raw Vegetable 1 Fat Free Food 14

Example of daily exchange diet: 1800 Kcals daily EVENING SNACK 2 graham crackers 1 c 2% milk 1 Bread 1 Milk 2009 15

The Exchange Diet For more information please visit: http: //www. diabetes. org/home. jsp 2009 16

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 2009 17

Meal Replacement Plan 4 types of meal replacers: Powder mixes Shakes Bars Prepackaged Meals 2009 18

Meal Replacement Plan An intake of five fruits and vegetables is recommended. § Effective § Convenient § Nutritionally balanced 2009 19

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 2009 20

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 2009 21

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 2009 22

Exercise Energy Balance = maintaining weight. Positive energy balance leads to weight gain. Negative energy balance leads to weight loss. 2009 23

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. 2009 24

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. 2009 25

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 2009 Using aerobic equipment (treadmill, stationary bike) 26

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. 2009 27

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. 2009 28

VLCD: Facts § Not recommended for pregnant or breastfeeding women § Not appropriate for children or adolescents § Not recommended for older individuals 2009 29

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 2009 30

Group Approaches § Social support § integration into social network and positive interactions with others. § Individual feels support, acceptance, and encouragement by others. 2009 31

Behavior Treatment § Need to change one’s approach § thinking § feelings § actions to eating and physical activity. 2009 32

Behavioral targets Weight = Total energy intake _ Eating Activity Total energy expenditure Targets of behavioral therapy 2009 33

Behavior Therapy: Important Components 1. Making Lifestyle Change a Priority 2. Establishing a Plan for Success 2009 34

Behavior Therapy: Important Components 3. Setting Goals § § 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. 2009 35

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. 2009 36

Behavior Therapy: Important Concepts 5. Avoiding a Food Chain Reaction § Stimulus control. § Learning to recognize cues. 2009 37

Behavior Therapy: Important Concepts § § § 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 2009 38

Behavior Therapy: Important Concepts 6. Changing Eating and Activity Patterns § § § slowing pace of eating reducing portion sizes measuring food intake leaving food on plate improving food choices eliminating second servings 2009 39

Behavior Therapy: Important Concepts Changing Eating and Activity Patterns § Programmed exercise vs lifestyle § Lifestyle activity preferable for weight loss. 2009 40

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 2009 41

Behavior Therapy: Important Concepts 8. Cognitive Behavioral Strategies § Traditional behavioral treatment components with emphasis on thinking patterns that may affect eating behaviors. 2009 42

Behavior Therapy: Important Concepts 9. Stress Management § Stress is a primary predictor of overeating and relapse. § Stress management skills 2009 43

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 2009 44

Drug Therapy Commonly prescribed drugs for the treatment of obesity include: Phentermine Sibutramine Orlistat 2009 45

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. 2009 46

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. 2009 47

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. 2009 48

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 2009 49

Types of GI surgeries available Restrictive Malabsorptive Combined restrictive/malabsorptive 2009 50

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. 2009 51

Restrictive Operations: Examples 1. Adjustable gastric banding A band is clamped to create a pouch. 2009 52

Restrictive Operations: Examples 2. Vertical banded gastroplasty. Uses the band staples to create a small pouch. Not commonly used today. 2009 53

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. 2009 54

Restrictive Operations: Disadvantages 1. 2. 3. 4. 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. 2009 55

Restrictive Operations: Risks 1. 2. 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! 2009 56

Malabsorptive Operations § The main malabsorptive operation is the jejunoileal bypass which is not performed today because of the high incidence of health complications. 2009 57

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. 2009 58

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. 2009 59

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. 2009 60

Combined Operations: Disadvantages 1. 2. 3. 4. 5. 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. 2009 61

Combined Operations: Risks 1. 2. 3. May lead to complications. Greater risk for abdominal hernias. The risk of death may be higher. 2009 62

Bariatric Surgery: Facts Procedures cost from $20, 000 to $35, 000. Medical insurance coverage varies by state. 2009 63

NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) The patient should consider the following questions prior to weight loss surgery: 1. 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? 2009 64

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? 2009 65

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. 2009 66

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. 2009 67

References: Behavior Therapy and VLCD Information § http: //www. medhelp. org/NIHlib/GF-390. html § Foreyt, J. P. , & Poston, W. S. C. , Jr. (1998 a). The role of the behavioral counselor in obesity treatment. J Am Diet Assoc, 10(Supplement 2), S 27 -S 30 § Foreyt, J. P. , & Poston, W. S. C. , Jr. (1998 b). What is the role of cognitive-behavior therapy in patient management? Obes Res, 6(Supplement 1), 18 S-22 S § 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 2009 68

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 : 2009 69

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: S 30 -S 35. § 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: S 18 -S 29. 2009 70

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. 3 rd Ed. American Society for Bariatric. Surgery, Gainesville, FL 2001. § http: //win. niddk. nih. gov/publications/gastric. htm § Escott-Stump, S. Nutrition and Diagnosis-Related Care. 5 th Edition. 2002. 2009 71

References: Exercise § 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. § Mc. Ardle WD, Katch FL, and Katch VL. Exercise Physiology: Energy, Nutrition and Human Performance, 5 th Edition. Lippincott Williams & Wilkins 2004. 2009 72

References: Diet § § § 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, De. Looy 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): S 146. 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. 2009 73

Pennington Biomedical Research Center Division of Education § Heli J. Roy, Ph. D, RD § Beth Kalicki § Division of Education Phillip Brantley, Ph. D, Director Pennington Biomedical Research Center Claude Bouchard, Ph. D, Executive Director Edited: October 2009 74

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. 2009 75