Dietary Therapy: A diet that is individually planned and takes into account the patient's overweight status in order to help create a deficit of 500 to 1,000 kcal/day should be an integral part of any weight loss program. A patient may choose a diet of 1,000 to 1,200 kcal/day for women and 1,200 to 1,500 kcal/day for men. Depending on the patient's risk status, the low-calorie diet (LCD) recommended should be consistent with the NCEP's Step I or Step II Diet (see page 74 of the guidelines). Besides decreasing saturated fat, total fats should be 30 percent or less of total calories. Reducing the percentage of dietary fat alone will not produce weight loss unless total calories are also reduced. Isocaloric replacement of fat with carbohydrates will reduce the percentage of calories from fat but will not cause weight loss. Reducing dietary fat, along with reducing dietary carbohydrates, usually will be needed to produce the caloric deficit needed for an acceptable weight loss. When fat intake is reduced, priority should be given to reducing saturated fat to enhance lowering of LDL-cholesterol levels. Frequent contacts with the practitioner during dietary therapy help to promote weight loss and weight maintenance at a lower weight.
Physical Activity: An increase in physical activity is an important component of weight loss therapy, although it will not lead to substantially greater weight loss over 6 months. Most weight loss occurs because of decreased caloric intake. Sustained physical activity is most helpful in the prevention of weight regain. In addition, it has a benefit in reducing cardiovascular and diabetes risks beyond that produced by weight reduction alone. For most obese patients, exercise should be initiated slowly, and the intensity should be increased gradually. The exercise can be done all at one time or intermittently over the day. Initial activities may be walking or swimming at a slow pace. The patient can start by walking 30 minutes for 3 days a week and can build to 45 minutes of more intense walking at least 5 days a week. With this regimen, an additional expenditure of 100 to 200 calories per day can be achieved. All adults should set a long-term goal to accumulate at least 30 minutes or more of moderate-intensity physical activity on most, and preferably all, days of the week. This regimen can be adapted to other forms of physical activity, but walking is particularly attractive because of its safety and accessibility. Patients should be encouraged to increase "every day" activities such as taking the stairs instead of the elevator. With time, depending on progress and functional capacity, the patient may engage in more strenuous activities. Competitive sports, such as tennis and volleyball, can provide an enjoyable form of exercise for many, but care must be taken to avoid injury. Reducing sedentary time is another strategy to increase activity by undertaking frequent, less strenuous activities.
Behavior Therapy: Strategies, based on learning principles such as reinforcement, that provide tools for overcoming barriers to compliance with dietary therapy and/or increased physical activity are helpful in achieving weight loss and weight maintenance. Specific strategies include self-monitoring of both eating habits and physical activity, stress management, stimulus control, problem solving, contingency management, cognitive restructuring, and social support.
Combined Therapy: A combined intervention of behavior therapy, an LCD, and increased physical activity provides the most successful therapy for weight loss and weight maintenance. This type of intervention should be maintained for at least 6 months before con sidering pharmacotherapy.
Pharmacotherapy: In carefully selected patients, appropriate drugs can augment LCDs, physical activity, and behavior therapy in weight loss. Weight loss drugs that have been approved by the FDA for long-term use can be useful adjuncts to dietary therapy and physical activity for some patients with a BMI of > 30 with no concomitant risk factors or diseases, and for patients with a BMI of > 27 with concomitant risk factors or diseases. The risk factors and diseases considered important enough to warrant pharmacotherapy at a BMI of 27 to 29.9 are hypertension, dyslipi-demia, CHD, type 2 diabetes, and sleep apnea. Continual assessment by the physician of drug therapy for efficacy and safety is necessary.
At the present time, sibutramine is available for long-term use. (Note: FDA approval of orlistat is pending a resolution of labeling issues and results of Phase III trials.) It enhances weight loss modestly and can help facilitate weight loss maintenance. Potential side effects with drugs, nonetheless, must be kept in mind. With sibutramine, increases in blood pressure and heart rate may occur. Sibutramine should not be used in patients with a history of hypertension, CHD, congestive heart failure, arrhythmias, or history of stroke. With orlistat, fat soluble vitamins may require replacement because of partial malabsorption. All patients should be carefully monitored for these side effects.
Weight Loss Surgery: Weight loss surgery is one option for weight reduction in a limited number of patients with clinically severe obesity, i.e., BMIs > 40 or > 35 with comorbid conditions. Weight loss surgery should be reserved for patients in whom efforts at medical therapy have failed and who are suffering from the complications of extreme obesity.
Gastrointestinal surgery (gastric restriction [vertical gastric banding] or gastric bypass [Roux-en Y]) is an intervention weight loss option for motivated subjects with acceptable operative risks. An integrated program must be in place to provide guidance on diet, physical activity, and behavioral and social support both prior to and after the surgery.
■ Adapt Weight Loss Programs To Meet the Needs of Diverse Patients. Standard treatment approaches for overweight and obesity must be tailored to the needs of various patients or patient groups. Large individual variation exists within any social or cultural group; furthermore, substantial overlap among subcultures occurs within the larger society. There is, therefore, no "cookbook" or standardized set of rules to optimize weight reduction with a given type of patient. However, to be more culturally sensitive and to incorporate patient characteristics in obesity treatment programs: consider and adapt the setting and staffing for the program; consider how the obesity treatment program integrates into other aspects of patient health care and self care; and expect and allow for program modifications based on patient responses and preferences.
The issues of weight reduction after age 65 involve such questions as: does weight loss reduce risk factors in older adults; are there risks associated with obesity treatment that are unique to older adults; and does weight reduction prolong the lives of older adults? Although there is less certainty about the importance of treating overweight at older ages than at younger ages, a clinical decision to forgo obesity treatment in older adults should be guided by an evaluation of the potential benefit of weight reduction and the reduction of risk for future cardiovascular events.
In the obese patient who smokes, smoking cessation is a major goal of risk factor management. Many well-documented health benefits accompany smoking cessation, but a major obstacle to cessation has been the attendant weight gain observed in about 80 percent of quitters. This weight gain averages 4.5 to 7 lb, but in 13 percent of women and 10 percent of men, weight gain exceeds 28 lb. Weight gain that accompanies smoking cessation has been quite resistant to most dietary, behavioral, or physical activity interventions.
The weight gained with smoking cessation is less likely to produce negative health consequences than would continued smoking. For this reason, smoking cessation should be strongly advocated regardless of baseline weight. Prevention of weight gain through diet and physical activity should be stressed. For practical reasons, it may be prudent to avoid initiating smoking cessation and weight loss therapy simultaneously. If weight gain ensues after smoking cessation, it should be managed vigorously according to the guidelines outlined in this report. Although short-term weight gain is a common side effect of smoking cessation, this gain does not rule out the possibility of long-term weight control.
SUMMARY OF EVIDENCE-BASED RECOMMENDATIONS
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