ROSEWOOD HEALTH CARE
Obesity is a major international public health problem and Americans are among the heaviest people in the world. The percentage of obese people in the United States has risen steadily
Many people find that although they initially lose weight by dieting, they quickly regain the weight after the diet ends. Because it so hard to keep weight off over time, it is important to have as much information and support as possible before starting a diet. You are most likely to be successful in losing weight and keeping it off when you believe that your body weight can be controlled.
This article discusses how to get started with a weight loss plan
STARTING A WEIGHT LOSS PROGRAM — Some people like to talk to their health care professional to get help choosing the best plan, monitoring progress, and getting advice and support along the way.
To know what treatment (or combination of treatments) will work best, determine your body mass index (BMI) and waist circumference (measurement). The BMI is calculated from your height and weight
œA person with a BMI between 25 and 29.9 is considered overweight
œA person with a BMI of 30 or greater is considered to be obese
A waist circumference greater than 35 inches (88 cm) in women and 40 inches (102 cm) in men increases the risk of obesity-related complications, such as heart disease and diabetes. People who are obese and who have a larger waist size may need more aggressive weight loss treatment than others. Talk to your health care professional for advice.
Types of treatment — Based on your measurements and your medical history, your doctor or nurse can determine what combination of weight loss treatments would work best for you. Treatments may include changes in lifestyle, exercise, dieting and, in some cases, weight loss medicines or weight loss surgery. Weight loss surgery, also called bariatric surgery, is reserved for people with severe obesity who have not responded to other weight loss treatments.
SETTING A WEIGHT LOSS GOAL — It is important to set a realistic weight loss goal. Your first goal should be to avoid gaining more weight and staying at your current weight (or within 5 percent or five pounds). Many people have a "dream" weight that is difficult or impossible to achieve.
People at high risk of developing diabetes who are able to lose 5 percent of their body weight and maintain this weight will reduce their risk of developing diabetes by about 50 percent and reduce their blood pressure. This is a success.
Losing more than 15 percent of your body weight and staying at this weight is an extremely good result, even if you never reach your "dream" or "ideal" weight.
LIFESTYLE CHANGES — Programs that help you to change your lifestyle are usually run by psychologists, nutritionists, or other professionals. The goals of lifestyle changes are to help you change your eating habits, become more active, and be more aware of how much you eat and exercise, helping you to make healthier choices.
This type of treatment can be broken down into three steps:
œThe triggers that make you want to eat
œEating
œWhat happens after you eat
Triggers to eat — Determining what triggers you to eat involves figuring out what foods you eat and where and when you eat. To figure out what triggers you to eat, keep a record for a few days of everything you eat, the places where you eat, how often you eat, and the emotions you were feeling when you ate.
For some people, the trigger is related to a certain time of day or night. For others, the trigger is related to a certain place, like sitting at a desk working.
Eating — You can change your eating habits by breaking the chain of events between the trigger for eating and eating itself. There are many ways to do this. For instance, you can:
œLimit where you eat to a few places (eg, dining room)
œRestrict the number of utensils (eg, only a fork) used for eating
œDrink a sip of water between each bite
œChew your food a certain number of times
œGet up and stop eating every few minutes
The types of foods we eat on a regular basis are related to whether we gain or lose weight over time. Whole grains, fruits, vegetables, nuts, and yogurt are associated with lower weight over four years, as contrasted with weight gain seen when eating french fried potatoes or chips, sugar-sweetened beverages, and red or processed meats
What happens after you eat — Rewarding yourself for good eating behaviors can help you to develop better habits. This is not a reward for weight loss; instead, it is a reward for changing unhealthy behaviors toward healthy ones.
Do not use food as a reward. Some people find money, clothing, or personal care (eg, a haircut, manicure, or massage) to be effective rewards. Treat yourself immediately after making better eating choices to reinforce the value of the good behavior.
You need to have clear behavior goals and you must have a time frame for reaching your goals. Reward small changes along the way to your final goal.
Other factors that contribute to successful weight loss — Changing your behavior involves more than just changing unhealthy eating habits; it also involves finding people around you to support your weight loss, reducing stress, and learning to be strong when tempted by food.
œEstablish a "buddy" system – Having a friend or family member available to provide support and reinforce good behavior is very helpful. The support person needs to understand your goals.
œLearn to be strong – Learning to be strong when tempted by food is an important part of losing weight. As an example, you will need to learn how to say "no" and continue to say no when urged to eat at parties and social gatherings. Develop strategies for events before you go, such as eating before you go or taking low-calorie snacks and drinks with you.
œDevelop a support system – Having a support system is helpful when losing weight. This is why many commercial groups are successful. Family support is also essential; if your family does not support your efforts to lose weight, this can slow your progress or even keep you from losing weight.
œPositive thinking – People often have conversations with themselves in their head; these conversations can be positive or negative. If you eat a piece of cake that was not planned, you may respond by thinking, "Oh, you stupid idiot, you've blown your diet!" and as a result, you may eat more cake.
A positive thought for the same event could be, "Well, I ate cake when it was not on my plan. Now I should do something to get back on track." A positive approach is much more likely to be successful than a negative one.
œReduce stress – Although stress is a part of everyday life, it can trigger uncontrolled eating in some people. It is important to find a way to get through these difficult times without eating or by eating low-calorie food, like raw vegetables. It may be helpful to imagine a relaxing place that allows you to temporarily escape from stress. With deep breaths and closed eyes, you can imagine this relaxing place for a few minutes.
œSelf-help programs – Self-help programs like Weight Watchers, Overeaters Anonymous, and Take Off Pounds Sensibly (TOPS) work for some people. As with all weight loss programs, you are most likely to be successful with these plans if you make long-term changes in how you eat.
CHOOSING A DIET OR NEW EATING PLAN — A calorie is a unit of energy found in food. Your body needs calories to function. The goal of any diet is to burn up more calories than you eat.
How quickly you lose weight depends upon several factors, such as your age, gender, and starting weight.
œOlder people have a slower metabolism than young people, so they lose weight more slowly.
œMen lose more weight than women of similar height and weight when dieting because they use more energy.
œPeople who are extremely overweight lose weight more quickly than those who are only mildly overweight.
How many calories do I need? — You can estimate the number of calories you need per day based upon your current (or target) weight, gender, and activity level for women and for men
In general, it is best to choose foods that contain enough protein, carbohydrates, essential fatty acids, and vitamins.
Try not to drink alcohol or drinks with added sugar, and most sweets (candy, cakes, cookies), since they rarely contain important nutrients.
Portion-controlled diets — One simple way to diet is to buy packaged foods, like frozen low-calorie meals or meal-replacement canned drinks. A typical meal plan for one day may include:
œA meal-replacement drink or breakfast bar for breakfast
œA meal-replacement drink or a frozen low-calorie (250 to 350 calories) meal for lunch
œA frozen low-calorie meal or other prepackaged, calorie-controlled meal, along with extra vegetables for dinner
This would give you 1000 to 1500 calories per day.
Low-fat diet — To reduce the amount of fat in your diet, you can:
œEat low-fat foods. Low-fat foods are those that contain less than 30 percent of calories from fat. Fat is listed on the food facts label
œCount fat grams. For a 1500 calorie diet, this would mean about 45 g or fewer of fat per day.
Low-carbohydrate diet — Low- and very-low-carbohydrate diets (eg, Atkins diet, South Beach diet) have become popular ways to lose weight quickly.
œWith a very-low-carbohydrate diet, you eat between 0 and 60 grams of carbohydrates per day (a standard diet contains 200 to 300 grams of carbohydrates).
œWith a low-carbohydrate diet, you eat between 60 and 130 grams of carbohydrates per day.
Carbohydrates are found in fruits, vegetables, and grains (including breads, rice, pasta, and cereal), alcoholic beverages, and in dairy products. Meat and fish do not contain carbohydrates.
Side effects of very-low-carbohydrate diets can include constipation, headache, bad breath, muscle cramps, diarrhea, and weakness.
Mediterranean diet — The term "Mediterranean diet" refers to a way of eating that is common in olive-growing regions around the Mediterranean Sea. Although there is some variation in Mediterranean diets, there are some similarities. Most Mediterranean diets include:
œA high level of monounsaturated fats (from olive or canola oil, walnuts, pecans, almonds) and a low level of saturated fats (from butter).
œA high amount of vegetables, fruits, legumes, and grains (7 to 10 servings of fruits and vegetables per day).
œA moderate amount of milk and dairy products, mostly in the form of cheese. Use low-fat dairy products (skim milk, fat-free yogurt, low-fat cheese).
œA relatively low amount of red meat and meat products. Substitute fish or poultry for red meat.
œFor those who drink alcohol, a modest amount (mainly as red wine) may help to protect against cardiovascular disease. A modest amount is up to one (4 ounce) glass per day for women and up to two glasses per day for men.
Which diet is best? — Studies have compared different diets, including:
œVery-low-carbohydrate (Atkins)
œMacronutrient balance controlling glycemic load (Zone)
œReduced-calorie (Weight Watchers)
œVery-low-fat (Ornish)
No one diet is "best" for weight loss . Any diet will help you to lose weight if you stick with the diet. Therefore, it is important to choose a diet that includes foods you like.
Fad diets — Fad diets often promise quick weight loss (more than 1 to 2 pounds per week) and may claim that you do not need to exercise or give up favorite foods. Some fad diets cost a lot of money because you have to pay for seminars, pills, or packaged food. Fad diets generally lack any scientific evidence that they are safe and effective, but instead rely on "before" and "after" photos or testimonials.
Diets that sound too good to be true usually are. These plans are a waste of time and money and are not recommended. A doctor, nurse, or nutritionist can help you find a safe and effective way to lose weight and keep it off.
WEIGHT LOSS MEDICINES — Taking a weight loss medicine may be helpful when used in combination with diet, exercise, and lifestyle changes. However, it is important to understand the risks and benefits of these medicines. It is also important to be realistic about your goal weight using a weight loss medicine; you may not reach your "dream" weight, but you may be able to reduce your risk of diabetes or heart disease.
Weight loss medicines may be recommended for people who have not been able to lose weight with diet and exercise who have a:œBMI of 30 or more
œBMI between 27 and 29.9 and have other medical problems, such as diabetes, high cholesterol, or high blood pressure, and who have failed to achieve weight loss goals through diet and exercise alone.
Orlistat — Orlistat (Xenical 120 mg capsules) is a medicine that reduces the amount of fat your body absorbs from the foods you eat. A lower-dose version is now available without a prescription (Alli 60 mg capsules) in many countries, including the United States. The medicine is recommended three times per day, taken with a meal; you can skip a dose if you skip a meal or if the meal contains no fat.
After one year of treatment with orlistat, the average weight loss is approximately 11.7 pounds (5.3 kg) or 8 to 10 percent of initial body weight (4 percent more than in those who used lifestyle with a placebo). Cholesterol levels often improve and blood pressure sometimes falls. In people with diabetes, orlistat may help control blood sugar levels.
Side effects occur in 15 to 10 percent of people and may include stomach cramps, gas, diarrhea, leakage of stool, or oily stools. These problems are more likely when you take orlistat with a high-fat meal (if more than 30 percent of calories in the meal are from fat). Side effects usually improve as you learn to avoid high-fat foods. Severe liver injury has been reported rarely in patients taking orlistat, but it is not known if orlistat caused the liver problems [6].
Lorcaserin — Lorcaserin is a medicine that reduces appetite and thereby reduces body weight in men and women. Lorcaserin appears to have similar efficacy as orlistat. After one year, the mean weight loss is approximately 12.8 pounds (5.8 kg) compared with 6.4 pounds (2.9 kg) in the placebo group. Adverse effects of lorcaserin included headache, upper respiratory infections, nasopharyngitis, dizziness, and nausea, occurring in 18, 14.8, 13.4, 8, and 7.5 percent of patients, respectively.
The recommended dose of lorcaserin is 10 mg twice daily, taken with or without food. The response to therapy should be evaluated by week 12. Lorcaserin should be discontinued if patients do not lose 5 percent of body weight in 12 weeks.
Lorcaserin should not be used in individuals with reduced kidney function (creatinine clearance <30 mL/min). It is contraindicated during pregnancy. In addition, lorcaserin should not be used with other serotonergic drugs (eg, selective serotonin reuptake inhibitors, selective serotonin-norepinephrine reuptake inhibitors, bupropion, tricyclic antidepressants, and monamine oxidase inhibitors) because of the theoretical potential for serotonin syndrome.
Phentermine-extended release topiramate — Phentermine is a drug that reduces food intake by causing early satiety. Topiramate is used for the prevention of migraine headaches and epilepsy. Patients taking topiramate for these indications lose weight, but the mechanism is uncertain. In one year trials comparing the combination of phentermine and extended release topiramate (in one capsule) to placebo, patients lose approximately 8 to 10 percent of their bodyweight (mean weight loss 22.4 pounds [10.2 kg] compared with 3.1 pounds [1.4 kg] in the placebo group).
The initial dose of phentermine-topiramate is 3.75 to 23 mg for 14 days, followed by 7.5 to 46 mg thereafter. If after 12 weeks a 3 percent loss in baseline bodyweight is not achieved, the dose can be increased to 11.25 to 69 mg for 14 days, and then to 15 to 92 mg daily. If an individual does not lose 5 percent of body weight after 12 weeks on the highest dose, phentermine-topiramate should be discontinued gradually, as abrupt withdrawal of topiramate can cause seizures. Women of child-bearing age should have a pregnancy test before starting this drug and monthly thereafter.
The most common adverse events are dry mouth (13 to 21 percent), constipation (15 to 17 percent), and paraesthesia (14 to 21 percent). There is a dose-related increase in the incidence of psychiatric (eg, depression, anxiety) and cognitive (eg, disturbance in attention) adverse events. Although blood pressure improves slightly with combination phentermine-extended release topiramate, there is an increase in heart rate (0.6 to 1.6 beats/min) compared with placebo.
This combination medicine is contraindicated during pregnancy because of an increased risk of orofacial clefts in infants exposed during the first trimester of pregnancy. We do not use phentermine-topiramate for patients with cardiovascular disease (hypertension or coronary heart disease) or in pregnant women. Phentermine-topiramate may be used in obese postmenopausal women and men without cardiovascular disease, particularly those who do not tolerate orlistat or lorcaserin.
Dietary supplements — Dietary supplements are widely used by people who are trying to lose weight, although the safety and efficacy of these supplements are often unproven. A few of the more common diet supplements are discussed below; none of these are recommended because they have not been studied carefully and there is no proof that they are safe or effective.
œChitosan and wheat dextrin are ineffective for weight loss and their use is not recommended.
œEphedra, a compound related to ephedrine, is no longer available in the United States due to safety concerns. Many nonprescription diet pills previously contained ephedra. Although some studies have shown that ephedra helps with weight loss, there can be serious side effects (psychiatric symptoms, palpitations, and stomach upset), including death.
œThere are not enough data about the safety and efficacy of chromium, ginseng, glucomannan, green tea, hydroxycitric acid, L-carnitine, psyllium, pyruvate supplements, St. John’s wort, and conjugated linoleic acid.
œTwo supplements from Brazil, Emagrece Sim (also known as the Brazilian diet pill) and Herbathin dietary supplement, have been shown to contain prescription drugs.
œHoodia gordonii is a dietary supplement derived from a plant in South Africa. It is not recommended because there is no proof that it is safe or effective.
œBitter orange (Citrus aurantium) can increase your heart rate and blood pressure and is not recommended.
œHuman chorionic gonadotropin is a hormonal preparation similar to luteinizing hormone that is given by injection. There have been several studies showing that these injections are not any better than placebo injections
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LIFESTYLE MODIFICATION
The initial management of overweight and obesity is lifestyle intervention, a combination of diet, exercise, and behavioral modification. This combination can produce weight losses of 5 to 10 percent. Some patients eventually require the addition of pharmacologic therapy or bariatric surgery. The appropriate application of and indications for these additional measures remain in flux.
The goal of behavioral therapy is to help patients make long-term changes in their eating behavior by modifying and monitoring their food intake, modifying their physical activity, and controlling cues and stimuli in the environment that trigger eating. The use of behavioral strategies to treat obesity in adults is reviewed here. Other therapies for obesity, including drug therapy, specific diets, and specific exercise programs, are reviewed separately. Obesity in children and adolescents is also reviewed separately.
ASSUMPTIONS AND EXPECTATIONS — There are two basic assumptions underlying behavioral therapy for overweight patients. The first is that obese individuals have learned maladaptive eating and exercise patterns that are contributing to weight gain and/or maintenance of their overweight state. The second is that these behaviors can be modified and that weight loss will result. With this theory, principles of learning from schools of classical and operant conditioning are applied in training new behaviors. Thus, behavioral treatment for the overweight patient seeks to alter the environment, to alter environmental reinforcement contingencies, and to shape eating behavior and physical activity.
One of the key elements of human nature is perseverance. This concept applies to the search for new ways to lose weight that occurs on an almost annual basis. This cycle of failure and renewed effort has been labeled as a "false hope syndrome" [1]. There are several reasons why self-change attempts fail:
œExpectations often exceed what is feasible
œPeople often predict that they will change more quickly and more easily than is possible
œPeople overestimate their abilities in many domains and are unaware that they are inaccurate
œPeople often believe that making a change will improve their lives more than can reasonably be expected
Dieters go through a number of explanations for their failure. The plateau that occurs with all weight loss efforts may be viewed by the individual trying to lose weight as the result of not trying hard enough. Some individuals blame the diet itself when it is unsuccessful. For the counselor, one option is to try another diet. However, cycling through the false hope syndrome often produces negative feelings and frustrations. While some individuals are able to overcome these barriers and successfully lose weight, the failure rates remain high.
ELEMENTS OF BEHAVIORAL STRATEGIES — Comprehensive lifestyle interventions usually provide a structured behavioral program that includes a number of components
œSelf-monitoring (keeping food diaries and activity records)
œControlling or modifying the stimuli that activate eating
œSlowing down the eating process
œGoal-setting
œBehavioral contracting and reinforcement
œNutrition education and meal planning
œModification of physical activity
œSocial support
œCognitive restructuring
œProblem-solving
These same behaviors are recommended to maintain lost weight, with the addition of frequent (ie, weekly or more often) monitoring of body weight.
Self-monitoring — Self-monitoring, often involving the use of food diaries, activity records, and self-weighing, is one of the elements in a successful behavioral weight loss program. The participants are instructed in how to record everything they eat and the calories in the food, as well as the situation in which they are eating. The National Weight Control registry reports that self-monitoring is one of the techniques most frequently used among patients who lose weight and maintain the weight loss . In a systematic review of 22 studies evaluating the relationship between self-monitoring and weight loss, there was a consistent association between self-monitoring (of weight, diet, and exercise) and successful weight loss . A variety of methods were used to perform self-monitoring, including paper diaries, internet applications, personal digital assistants, and digital scales for recording weight.
Stimulus control — Stimulus control is another element in a behavioral program . It focuses on gaining control over the environmental factors that activate eating, and eliminating or modifying the environmental factors that facilitate over-eating. Since food is a key issue in weight gain, participants are taught to buy more fresh fruits and vegetables, to prepare easy-to-eat lower calorie foods, and to place them prominently in the refrigerator or on the counter. The proximity of food and the shape and size of serving containers may influence how much is eaten
Stimulus control also includes making the act of eating a focus of its own. Thus, turning off the television set and putting down reading materials may allow the individual to concentrate on eating. Stimulus control in children who substituted active behaviors for sedentary behaviors was associated with a significantly smaller rise in body mass index (BMI) z-scores at six and at 12 months
Eating style — Since eating is central to ingesting food, slowing down the process may give "physiological" signals for fullness time to come into play. Two ways to slow down eating include concentrating on the tastes of the food and savoring what is being eaten by chewing more slowly. Other techniques might involve leaving the table briefly during a meal, and drinking water between bites or just prior to the meal
Setting realistic goals — Changes in eating behavior require time and commitment, and it is important for the patient and therapist to set realistic weight loss goals, such as 0.5 to 1 kg/week, or 5 to 10 percent of baseline weight within three to six months . To achieve this goal, participants are encouraged to reduce energy intake by 500 kcal/day, which can be done with diet instruction, provision of food, or the use of portion-controlled foods. Although this is a reasonable hypothesis, empirical data indicate no consistent negative association between ambitious goals and program completion or weight loss
Behavioral contracting and reinforcement — Reinforcing successful outcomes and providing small tokens for success may be beneficial. For example, patients can earn credit for gasoline or merchandise (not food) for successful completion of various activities in a behavior program.
Financial incentives can also serve to enhance weight loss. As an example, in a 24-week trial, 105 employees (BMI 30 to 40 kg/m2) were randomly assigned to receive financial incentive as individuals or as members of a five-member group, or to a control group with monthly weigh-ins. The financial reward was distributed at the end of each month to individuals who met a prescribed weight loss target. The group incentive participants shared the reward (which was five times the individual reward) evenly, but only among those who met the target weight loss goal. The five members of the group were unknown to each other. The group incentive participants lost significantly more weight than individual incentive and control groups (4.8, 1.7, and 0.5 kg, respectively) and also received larger payouts than individual incentive participants (USD $514 versus $128 over five months). The opportunity to earn a larger reward, by acquiring the incentive that other group members forfeited by not meeting the monthly goal, may have been a motivating factor for group incentive participants. This suggests that variable incentives within a group may be better than specified individual ones.
In contrast with financial incentives, social contingency, ie, having access to the group only if the participant met specific weight loss goals, did not improve weight loss
Nutritional education and meal planning — Nutrition education and meal planning are also good behavior strategies. Providing a defined meal structure results in greater weight loss than does the absence of such a structure . Use of portion-controlled plates or diets is one of the strategies for providing this structured environment for eating.
Dietary counseling appears to facilitate weight loss, particularly during the first year of weight loss programs
Use of meal replacements enhanced weight loss in the Look AHEAD (Action for Health in Diabetes) trial in the first four years, but their use diminished over the eight years in the trial, as did their relation to successful weight loss
Increasing physical activity — Increasing physical activity is another part of a successful behavioral program . Along with self-monitoring, increasing physical activity was a key element in success for members of the National Weight Control Registry, a group of more than 4000 individuals who had lost at least 13.6 kg (30 lbs) and kept it off for at least one year These individuals had lost an average of 33 kg and maintained it for an average of 5.7 years. Women in the Registry reported expending 2545 kcal/week in exercise, and men, 3293 kcal/week in exercise. This would be equivalent to about one hour per day of moderate-intensity activity, such as brisk walking . In addition, the amount of weight lost in the Look AHEAD trial over eight years was related to the amount of physical activity
Social support — Enhancing social support may also be a means for improving long-term weight loss Inclusion of family members or spouses is one way to accomplish this. There are both short-term and long-term benefits to programs that include strong family support. In a meta-analysis of four 12-month behavioral programs that included family members, mean weight loss in the family-based intervention was approximately 3 kg more than in the control behavioral programs
Social support can also work to the advantage of the family member not participating in the trial. In the Look AHEAD trial, which is a randomized trial of intensive lifestyle modification in patients with type 2 diabetes, the spouses of those in the intervention group lost 2.2 to 4.4 kg, whereas spouses of those in the control group gained up to 3.3 kg in body weight . The Look AHEAD trial is reviewed separately.
Other — Although unproven, a number of behavioral tools may help with weight loss:
œCognitive restructuring – Adopting positive rather than negative self-talk (for example, if one eats a piece of cake, choosing to exercise rather than blaming oneself)
œProblem-solving – Developing strategies to manage food intake in difficult situations such as restaurants and parties
œAssertiveness training – Learning to say "no"
œStress reduction – Identifying and reducing stressors that are triggers for eating
CHOICE OF INTERVENTION — For overweight and obese patients who are attempting to lose weight, we suggest weight loss programs that include behavior modification. A high-intensity program (at least 12 sessions over six months) with frequent reinforcement is preferred . A principal determinant of weight loss appears to be the degree of adherence to the program. Thus, patient preference is an important consideration when recommending any behavioral weight loss program.
There are several behavioral interventions that can achieve weight loss goals, including face-to-face (individual or group), internet-based, and mobile applications. These interventions use similar behavioral strategies, which are outlined above They can be delivered in many different settings, including healthcare offices, gyms/clubs, and commercial weight loss centers. Behavioral programs appear to be successful whether administered individually or in a group setting, and there is insufficient evidence to conclude that one is better than the other . While some patients might prefer individual therapy, the group setting may be more cost-effective, as a single therapist can handle up to 15 or more participants.
One of the major lessons of the past 30 years is that programs of greater length are more effective than those of shorter length In the 1970s, behavioral weight loss programs typically lasted eight weeks with an average weight loss of 3.8 kg, but by the 1990s, as treatment duration lengthened, typical weight loss was 8.5 kg after 21 weeks of treatment Combining behavioral therapy with other methods can enhance the magnitude and duration of weight loss.
Efficacy — Behavioral-based treatment programs improve weight loss results, at least in the short term As an example, in a systematic review of 38 trials assessing behaviorally-based interventions compared with usual care, most trials showed a statistically significant effect on weight loss with the intervention at 12 to 18 months . The interventions included regular patient education sessions (eg, healthy diet choices, physical activity, weight loss goals, barriers to weight loss), regular weight checks, and peer support. The intervention groups lost 1.5 to 5 kg, whereas controls lost little or no weight. Subjects participating in behavioral interventions that included more sessions (12 to 26) lost more weight (4 to 7 kg versus 1.5 to 4 kg) than those participating in fewer than 12 sessions.
A subsequent systematic review reported similar findings . Mean changes in weight from baseline ranged from a loss of 0.3 to 6.6 kg in the intervention groups compared with a gain of 0.9 to a loss of 2.0 kg in the control groups. Interventions that combined dietary therapy (reduced energy intake) and increased physical activity with behavioral therapy were more successful in reducing weight than interventions without all three components.
Behavioral interventions in conjunction with drug (orlistat) therapy are also more effective than routine care, as illustrated by the results of a randomized trial examining three different lifestyle interventions (usual care [quarterly primary care visits with five to seven minutes spent reviewing weight loss plans], brief counseling [usual care plus 10 to 15 minutes each month with a lifestyle coach], and enhanced counseling [brief counseling plus meal replacements, orlistat, or sibutramine]) in 390 obese adults . After two years, mean weight loss was 1.7, 2.9, and 4.6 kg, respectively. Initial weight decreased at least 5 percent in 21.5, 26, and 34.9 percent, respectively. These outcomes were significantly better in the enhanced lifestyle counseling group compared with usual care, but there were no significant differences among the other groups.
Interventions that are successful in reducing weight also reduce diabetes risk, particularly in patients with impaired glucose tolerance or impaired fasting glucose at baseline . There are few data on long-term health outcomes (mortality, cardiovascular disease). After a median follow-up of 9.6 years in the Look AHEAD (Action for Health in Diabetes) trial, which compared an intensive lifestyle intervention to a diabetes support and education control group, there was improvement in cardiovascular risk factors . However, there was no reduction in the primary outcome, cardiovascular mortality, possibly due to the lower than expected rates of cardiovascular events in both groups and to the small difference in weight loss between the two groups by study end.
Self-help or commercial weight loss programs — Commercial weight loss programs can be expensive, sometimes employ very low calorie diets, and only occasionally have been evaluated in controlled clinical trials . Since the commercial programs do not carry any higher risk than other dietary programs, the patient and health care provider can select among programs, with the recommendation that programs with clinically demonstrated efficacy be the first choice.
Self-help or commercial weight loss programs incorporate varying degrees of behavioral modification strategies. A systematic review of the major available programs in the United States reported the following
œThe two largest self-help programs were Take Off Pounds Sensibly (TOPS) and Overeaters Anonymous, both not-for-profit groups. There was little evidence to suggest that these programs are effective, but the costs and risks appear to be minimal. Some patients find the emotional support offered in these programs to be helpful. In a subsequent analysis of the TOPS national database, individuals with consecutive membership renewal lost 5.9 to 7.1 percent of their initial body weight over a one- to three-year period . Individuals with nonconsecutive renewals lost less weight.
œThe three largest commercial programs were Weight Watchers, Jenny Craig, and LA Weight Loss. At the time of the systematic review, only one of these, Weight Watchers, had funded clinical trials to determine efficacy. In a two-year, multicenter trial of 423 subjects randomly assigned to attendance at weekly meetings versus a "self-help" control group (two 20-minute sessions with a nutritionist and provision of printed materials), those in the Weight Watchers group lost 5.3 percent of their initial weight after one year, and maintained a loss of 3.2 percent after two years (compared with 1.5 and 0 percent, respectively, in the control group) .
In a subsequent trial comparing Jenny Craig with usual care (consultation with a dietician at baseline and six months and provision of printed material) in 442 overweight or obese women (mean body mass index [BMI] 34 kg/m2), subjects who participated in the Jenny Craig program lost significantly more weight after two years (6.8 to 7.9 percent of their initial weight, compared with 2.1 percent in the control group). This response is similar to the weight losses reported in the lifestyle arms of the Diabetes Prevention Program and the Look AHEAD trial . In both groups (Jenny Craig and usual care), weight loss occurred during the first 12 months, followed by a slight weight gain between 12 and 24 months. Attenuation of weight loss between 12 and 24 months was higher in the Jenny Craig group (27 percent versus 17 percent), suggesting greater difficulty with maintenance of weight loss . In addition, Jenny Craig participants were provided with free prepared meals and, therefore, the attrition rate was low. Whether the average obese patient who is paying for this plan will achieve similar results is unknown.
A trial from the United Kingdom compared six weight loss programs (three commercial programs and three provided by the National Health Service) with a minimal intervention comparator group that was provided with vouchers to a fitness center After 12 weeks, mean weight loss ranged from 4.4 to 1.4 kg. Participants in the commercial weight loss programs (Weight Watchers and Rosemary Conley) had significantly greater weight loss than the control group. After one year, only the Weight Watchers group had significantly greater weight loss than the comparator group (mean difference -2.38 kg, 95% CI -3.98 to -0.78). Weight Watchers had the highest proportion of persons attending 50 percent or more sessions, reinforcing attendance as an important determinant of success.
Internet-based programs — Internet-based weight loss programs are widely available, including some self-help and commercial weight loss programs that traditionally used only group meetings . Efficacy data for internet programs are mixed. In a systematic review of 18 weight loss trials, approximately 50 percent of the trials reported significantly greater weight loss among participants randomly assigned to the internet intervention than to control conditions . Several trials suggest that programs that include a behavior modification component are more effective than those that do not:
œIn one randomized trial of 124 overweight subjects, weight loss was greater after 12 months in those who used a structured, behavioral weight loss website when compared with a self-help commercial website (7.8 kg versus 3.4 kg, respectively)
œAnother trial reported that the addition of behavioral counseling (e-counseling) to a basic internet weight loss program resulted in greater weight loss at 12 months (4.4 kg versus 2 kg in subjects using the basic internet program only).
Thus, internet weight loss programs that incorporate behavior modification may be more effective than internet programs that do not.
Behavioral programs delivered remotely may be equally as effective as in-person programs. As an example, in a randomized trial of a face-to-face or a remote behavioral intervention compared with control (no intervention) in 415 obese patients, mean change in weight from baseline was similar at 24 months in the groups receiving the behavioral intervention (-5.1 and -4.6 kg, respectively, compared with -0.8 kg in the control group) . The remote intervention used telephone, a study-specific Web site, and email to provide patients with behavioral support. Participation in the face-to-face behavioral intervention declined during the course of the study. The median number of group sessions attended was 6.5 in the first six months and one in the next 18 months. The median number of individual sessions attended also decreased (four in the first six months and one in the last 18 months). In the remote group, the median number of completed phone calls was 14 of 15 recommended in the first six months and 16 of 18 recommended for the remainder of the trial. These data suggest that remote behavioral interventions present fewer barriers to adherence than in-person interventions.
MAINTENANCE OF WEIGHT LOSS — For overweight and obese patients who have lost weight, we suggest that behavior modification strategies be continued to minimize subsequent weight gain. Although many individuals have success losing weight with diet and/or behavioral therapy, most patients subsequently regain some or all of the lost weight. Behavioral interventions that target diet and physical activity may be helpful for maintaining weight loss . In a meta-analysis of 45 trials evaluating interventions to maintain weight loss after successful loss of ≥5 percent of body weight, behavioral interventions targeting diet and physical activity showed a small but significant benefit compared with controls (mean difference in weight regain -1.56 kg)
Data are conflicting on whether face-to-face interventions are more effective than internet-based interventions. Some patients may prefer internet programs for convenience and possibly lower cost.
This was illustrated in a trial of 314 patients who had lost a mean of 19 kg in the previous two years who were then randomly assigned to one of three groups: a group that received quarterly newsletters (control), a group that received internet-based behavioral intervention, and a group that received the behavioral intervention face-to-face . The content of the intervention, emphasizing self-weighing and self-regulation, was the same for the two experimental groups.
At 18 months of follow-up, patients in the face-to-face group gained less weight (2.5 kg) compared with the internet and control groups (4.7 and 4.9 kg, respectively). However, the proportion of participants who regained 2.3 kg or more was similar in the face-to-face and internet groups (45.7 and 54.8 percent, respectively), but higher in the control group (72.4 percent). Thus, intervention that emphasizes self-weighing and self-regulation may be helpful for maintenance of weight loss, particularly if delivered face-to-face.
Similar results were seen in a second trial in which patients were randomized to monthly personal contact for 30 months after an initial weight loss. They regained less weight over the next 18 months than patients randomized to an interactive technology-based intervention or self-directed control, but by the end of 30 months this difference was gone .
In contrast, a third, randomized trial of 254 subjects reported that maintenance of weight loss was as good with internet-based support as with in-person support . In this study, attendance at treatment meetings and chat room sessions, as well as frequency of self-monitoring, were related to successful maintenance.
SUMMARY AND RECOMMENDATIONS
œThe optimal management of overweight and obesity starts with a combination of diet, exercise, and behavioral modification. In addition, some patients eventually need the options of adding pharmacologic therapy or bariatric surgery.
œBehavioral treatment of obesity is a standard part of most treatment programs. The goal of this approach is to help patients make long-term changes in their eating behavior by modifying and monitoring their food intake, increasing their physical activity, and controlling cues and stimuli in the environment that trigger eating. Physical activity and self-monitoring are particularly important components for success.
œFor overweight and obese patients who are attempting to lose weight, we suggest weight loss programs that include behavior modification strategies A high-intensity program (at least 12 sessions over six months) with frequent reinforcement is preferred.
œA principal determinant of weight loss appears to be the degree of adherence to the program. Thus, patient preference is an important consideration when recommending any behavioral weight loss program. Some may prefer the convenience and possible lower cost of internet programs, while others may prefer the support provided by individual or group sessions.
œFor overweight and obese patients who have lost weight, we suggest that behavior modification strategies be continued to minimize subsequent weight gain
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