Obesity medical therapy: Difference between revisions

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__NOTOC__
__NOTOC__
{{Obesity}}
{{Obesity}}
{{CMG}}
{{CMG}}; {{AE}} {{KGH}}
 
==Overview==
==Overview==
==Medical Therapy==
The main treatment for obesity is to reduce body fat by [[dieting|eating fewer calories]] and [[Physical exercise|exercising]] more.  A beneficial side effect of exercise is to increase muscle, tendon, and ligament strength, which helps to prevent injury from accidents and vigorous activity.  Diet and exercise programs produce an average weight loss of approximately 8% of total body mass (excluding program drop-outs). Not all dieters are satisfied with these results, but a loss of as little as 5% of body mass can create large health benefits.
The main treatment for obesity is to reduce body fat by [[dieting|eating fewer calories]] and [[Physical exercise|exercising]] more.  A beneficial side effect of exercise is to increase muscle, tendon, and ligament strength, which helps to prevent injury from accidents and vigorous activity.  Diet and exercise programs produce an average weight loss of approximately 8% of total body mass (excluding program drop-outs). Not all dieters are satisfied with these results, but a loss of as little as 5% of body mass can create large health benefits.


Much more difficult than reducing body fat is keeping it off. Eighty to ninety-five percent of those who lose 10% or more of their [[body mass]] by dieting regain all that weight back within two to five years.  The body has systems that maintain its [[homeostasis]] at certain set points, including body weight. Therefore, keeping weight off generally requires making [[Physical exercise|exercise]] and [[Healthy diet|eating right]] a permanent part of a person's [[lifestyle]]. Certain nutrients, such as [[phenylalanine]], are natural appetite suppressants which allow resetting of the body's set point for body weight.
Much more difficult than reducing body fat is keeping it off. Eighty to ninety-five percent of those who lose 10% or more of their [[body mass]] by dieting regain all that weight back within two to five years.  The body has systems that maintain its [[homeostasis]] at certain set points, including body weight. Therefore, keeping weight off generally requires making [[Physical exercise|exercise]] and [[Healthy diet|eating right]] a permanent part of a person's [[lifestyle]]. Certain nutrients, such as [[phenylalanine]], are natural appetite suppressants which allow resetting of the body's set point for body weight.
== Clinical protocols ==
 
In a [[clinical practice guideline]] by the [[American College of Physicians]], the following five recommendations are made:<ref name=Snow2005>{{cite journal | author=Snow V, Barry P, Fitterman N, Qaseem A, Weiss K | title=Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians | journal=Ann Intern Med | year=2005 | pages=525-31 | volume=142 | issue=7 | id=PMID 15809464}} [http://www.annals.org/cgi/content/full/142/7/525 Fulltext].</ref>
== Clinical Practice Guidelines ==
[[Clinical practice guideline]]s are available<ref name="pmid24222017">{{cite journal| author=Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, Donato KA et al.| title=2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. | journal=Circulation | year= 2013 |volume=  | issue=  | pages=  | pmid=24222017 | doi=10.1161/01.cir.0000437739.71477.ee | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24222017  }} </ref><ref name="pmid15809464">{{cite journal| author=Snow V, Barry P, Fitterman N, Qaseem A, Weiss K, Clinical Efficacy Assessment Subcommittee of the American College of Physicians| title=Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians. | journal=Ann Intern Med | year= 2005 | volume= 142 | issue= 7 | pages= 525-31 | pmid=15809464 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15809464  }} </ref><ref name="pmid25253226">{{cite journal| author=Garvey WT, Garber AJ, Mechanick JI, Bray GA, Dagogo-Jack S, Einhorn D et al.| title=American association of clinical endocrinologists and american college of endocrinology consensus conference on obesity: building an evidence base for comprehensive action. | journal=Endocr Pract | year= 2014 | volume= 20 | issue= 9 | pages= 956-76 | pmid=25253226 | doi=10.4158/EP14279.CS | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25253226  }} </ref><ref name="pmid26641646">{{cite journal| author=Yumuk V, Tsigos C, Fried M, Schindler K, Busetto L, Micic D et al.| title=European Guidelines for Obesity Management in Adults. | journal=Obes Facts | year= 2015 | volume= 8 | issue= 6 | pages= 402-24 | pmid=26641646 | doi=10.1159/000442721 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26641646  }} </ref>; however, some of the guidelines do not follow recommendations for [[Clinical practice guideline|trustworthiness]] by the [[Institute of Medicine]]<ref name="pmid25253226"/><ref name="pmid26641646"/>.
 
===2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society (DO NOT EDIT) <ref name="pmid24222017">{{cite journal| author=Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, Donato KA et al.| title=2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. | journal=Circulation | year= 2013 |volume=  | issue=  | pages=  | pmid=24222017 | doi=10.1161/01.cir.0000437739.71477.ee | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24222017  }} </ref>===
====Matching Treatment Benefits With Risk Profiles (Reduction in Body Weight Effect on CVD Risk Factors, Events, Morbidity and Mortality) (DO NOT EDIT)====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Counsel overweight and obese adults with CV risk factors (high BP, hyperlipidemia and hyperglycemia), that lifestyle changes that produce even modest, sustained weight loss of 3%-5% produce clinically meaningful health benefits, and greater weight losses produces greater benefits.
 
*Sustained weight loss of 3%-5% is likely to result in clinically meaningful reductions in triglycerides, blood glucose, HbA1C, and the risk of developing type 2 diabetes;
*Greater amounts of weight loss will reduce BP, improve LDL–C and HDL–C, and reduce the need for medications to control BP, blood glucose and lipids as well as further reduce triglycerides and blood glucose. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}
====Diets for Weight Loss (Dietary Strategies for Weight Loss) (DO NOT EDIT)====
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss, as part of a comprehensive lifestyle intervention. Any 1 of the following methods can be used to reduce food and calorie intake:
*Prescribe 1,200–1,500 kcal/day for women and 1,500–1,800 kcal/day for men (kcal levels are usually adjusted for the individual’s body weight);
*Prescribe a 500 kcal/day or 750 kcal/day energy deficit; or
*Prescribe one of the evidence-based diets that restricts certain food types (such as high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Prescribe a calorie-restricted diet, for obese and overweight individuals who would benefit from weight loss, based on the patient’s preferences and health status and preferably refer to a nutrition A (Strong) professional* for counseling. A variety of dietary approaches can produce weight loss in overweight and obese adults, as presented in CQ3, ES2. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}
 
===ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death - Obesity, Dieting, and Anorexia (DO NOT EDIT) <ref name="pmid16935995">{{cite journal| author=Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M et al.| title=ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. | journal=Circulation | year= 2006 | volume= 114 | issue= 10 | pages= e385-484 | pmid=16935995 | doi=10.1161/CIRCULATIONAHA.106.178233 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16935995}}</ref>===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Life-threatening [[ventricular arrhythmias]] in patients with obesity, [[anorexia]], or when dieting should be treated in the same manner that such [[arrhythmias]] are treated in patients with other diseases, including [[ICD]] and [[pacemaker]] implantation as required. Patients receiving ICD implantation should be receiving chronic optimal medical therapy and have reasonable expectation of survival with a good functional status for more than 1 y. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class III]]
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Prolonged, unbalanced, very low calorie, semistarvation diets are not recommended; they may be harmful and provoke life-threatening [[ventricular arrhythmias]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Programmed weight reduction in obesity and carefully controlled re-feeding in [[anorexia]] can effectively reduce the risk of [[ventricular arrhythmias]] and [[Sudden cardiac death|SCD]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
===ACP 2005 Guidelines for Pharmacologic and surgical management of obesity in primary care<ref name=Snow2005>{{cite journal | author=Snow V, Barry P, Fitterman N, Qaseem A, Weiss K | title=Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians | journal=Ann Intern Med | year=2005 | pages=525-31 | volume=142 | issue=7 | id=PMID 15809464}} [http://www.annals.org/cgi/content/full/142/7/525 Fulltext].</ref>===
 
In a [[clinical practice guideline]] by the [[American College of Physicians]], the following five recommendations are made:<ref name="pmid15809464">{{cite journal| author=Snow V, Barry P, Fitterman N, Qaseem A, Weiss K, Clinical Efficacy Assessment Subcommittee of the American College of Physicians| title=Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians. | journal=Ann Intern Med | year= 2005 | volume= 142 | issue= 7 | pages= 525-31 | pmid=15809464 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15809464  }} </ref>
# People with a BMI of over 30 should be counseled on diet, exercise and other relevant behavioral interventions, and set a realistic goal for weight loss.
# People with a BMI of over 30 should be counseled on diet, exercise and other relevant behavioral interventions, and set a realistic goal for weight loss.
# If these goals are not achieved, pharmacotherapy can be offered. The patient needs to be informed of the possibility of [[Adverse effect (medicine)|side-effects]] and the unavailability of long-term safety and efficacy data.
# If these goals are not achieved, pharmacotherapy can be offered. The patient needs to be informed of the possibility of [[Adverse effect (medicine)|side-effects]] and the unavailability of long-term safety and efficacy data.
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A [[clinical practice guideline]] by the [[US Preventive Services Task Force]] (USPSTF) concluded that the evidence is insufficient to recommend for or against routine behavioral counseling to promote a healthy diet in unselected patients in primary care settings, but that intensive behavioral dietary counseling is recommended in those with [[hyperlipidemia]] and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians.<ref>{{cite web |url=http://www.ngc.gov/summary/summary.aspx?ss=15&doc_id=3494 |title=Behavioral counseling in primary care to promote a healthy diet: recommendations and rationale. |accessdate=2007-05-22 |format= |work=}}</ref><ref name="pmid12554027">{{cite journal |author=Pignone MP, Ammerman A, Fernandez L, ''et al'' |title=Counseling to promote a healthy diet in adults: a summary of the evidence for the U.S. Preventive Services Task Force |journal=American journal of preventive medicine |volume=24 |issue=1 |pages=75-92 |year=2003 |pmid=12554027 |doi=}}</ref>
A [[clinical practice guideline]] by the [[US Preventive Services Task Force]] (USPSTF) concluded that the evidence is insufficient to recommend for or against routine behavioral counseling to promote a healthy diet in unselected patients in primary care settings, but that intensive behavioral dietary counseling is recommended in those with [[hyperlipidemia]] and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians.<ref>{{cite web |url=http://www.ngc.gov/summary/summary.aspx?ss=15&doc_id=3494 |title=Behavioral counseling in primary care to promote a healthy diet: recommendations and rationale. |accessdate=2007-05-22 |format= |work=}}</ref><ref name="pmid12554027">{{cite journal |author=Pignone MP, Ammerman A, Fernandez L, ''et al'' |title=Counseling to promote a healthy diet in adults: a summary of the evidence for the U.S. Preventive Services Task Force |journal=American journal of preventive medicine |volume=24 |issue=1 |pages=75-92 |year=2003 |pmid=12554027 |doi=}}</ref>


=== Exercise ===
== Exercise ==
Exercise requires energy (calories).  Calories are stored in body fat. The body breaks down its fat stores in order to provide energy during prolonged [[aerobic exercise]]. The largest muscles in the body are the leg muscles, and naturally these burn the most calories, which make walking, running, and cycling among the most effective forms of exercise for reducing body fat.
Exercise requires energy (calories).  Calories are stored in body fat. The body breaks down its fat stores in order to provide energy during prolonged [[aerobic exercise]]. The largest muscles in the body are the leg muscles, and naturally these burn the most calories, which make walking, running, and cycling among the most effective forms of exercise for reducing body fat.


A [[meta-analysis]] of [[randomized controlled trials]] by the international [[Cochrane Collaboration]] found that "exercise combined with diet resulted in a greater weight reduction than diet alone".<ref name="pmid17054187">{{cite journal |author=Shaw K, Gennat H, O'Rourke P, Del Mar C |title=Exercise for overweight or obesity |journal=Cochrane database of systematic reviews (Online) |volume= |issue=4 |pages=CD003817 |year=2006 |pmid=17054187 |doi=10.1002/14651858.CD003817.pub3}}</ref>
A [[meta-analysis]] of [[randomized controlled trials]] by the international [[Cochrane Collaboration]] found that "exercise combined with diet resulted in a greater weight reduction than diet alone".<ref name="pmid17054187">{{cite journal |author=Shaw K, Gennat H, O'Rourke P, Del Mar C |title=Exercise for overweight or obesity |journal=Cochrane database of systematic reviews (Online) |volume= |issue=4 |pages=CD003817 |year=2006 |pmid=17054187 |doi=10.1002/14651858.CD003817.pub3}}</ref>


=== Dieting ===
== Dieting ==
{{main|Dieting}}
{{main|Dieting}}


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: "The higher discontinuation rates for the Atkins and Ornish diet groups suggest many individuals found these diets to be too extreme"
: "The higher discontinuation rates for the Atkins and Ornish diet groups suggest many individuals found these diets to be too extreme"


====Low carbohydrate versus low fat====
===Low Carbohydrate versus Low Fat===
{{main|Medical research related to low-carbohydrate diets}}
{{main|Medical research related to low-carbohydrate diets}}
Many studies have focused on diets that reduce calories via a low-carbohydrate ([[Atkins diet]], [[Zone diet]]) diet versus a low-fat diet ([[LEARN diet]], [[Ornish diet]]). The [[Nurses' Health Study]], an observational [[cohort study]], found that low carbohydrate diets based on vegetable sources of fat and protein are associated with less [[coronary heart disease]].<ref name="pmid17093250">{{cite journal |author=Halton TL, Willett WC, Liu S, ''et al'' |title=Low-carbohydrate-diet score and the risk of coronary heart disease in women |journal=N. Engl. J. Med. |volume=355 |issue=19 |pages=1991-2002 |year=2006 |pmid=17093250 |doi=10.1056/NEJMoa055317}}</ref>
Many studies have focused on diets that reduce calories via a low-carbohydrate ([[Atkins diet]], [[Zone diet]]) diet versus a low-fat diet ([[LEARN diet]], [[Ornish diet]]). The [[Nurses' Health Study]], an observational [[cohort study]], found that low carbohydrate diets based on vegetable sources of fat and protein are associated with less [[coronary heart disease]].<ref name="pmid17093250">{{cite journal |author=Halton TL, Willett WC, Liu S, ''et al'' |title=Low-carbohydrate-diet score and the risk of coronary heart disease in women |journal=N. Engl. J. Med. |volume=355 |issue=19 |pages=1991-2002 |year=2006 |pmid=17093250 |doi=10.1056/NEJMoa055317}}</ref>
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The [[Women's Health Initiative]] Randomized Controlled Dietary Modification Trial<ref name="pmid16391215">{{cite journal |author=Howard BV, Manson JE, Stefanick ML, ''et al'' |title=Low-fat dietary pattern and weight change over 7 years: the Women's Health Initiative Dietary Modification Trial |journal=JAMA |volume=295 |issue=1 |pages=39-49 |year=2006 |pmid=16391215 |doi=10.1001/jama.295.1.39}}</ref> found that a diet of total fat to 20% of energy and increasing consumption of vegetables and fruit to at least 5 servings daily and grains to at least 6 servings daily resulted in:
The [[Women's Health Initiative]] Randomized Controlled Dietary Modification Trial<ref name="pmid16391215">{{cite journal |author=Howard BV, Manson JE, Stefanick ML, ''et al'' |title=Low-fat dietary pattern and weight change over 7 years: the Women's Health Initiative Dietary Modification Trial |journal=JAMA |volume=295 |issue=1 |pages=39-49 |year=2006 |pmid=16391215 |doi=10.1001/jama.295.1.39}}</ref> found that a diet of total fat to 20% of energy and increasing consumption of vegetables and fruit to at least 5 servings daily and grains to at least 6 servings daily resulted in:
* no reduction in cardiovascular disease<ref name="pmid16467234">{{cite journal |author=Howard BV, Van Horn L, Hsia J, ''et al'' |title=Low-fat dietary pattern and risk of cardiovascular disease: the Women's Health Initiative Randomized Controlled Dietary Modification Trial |journal=JAMA |volume=295 |issue=6 |pages=655-66 |year=2006 |pmid=16467234 |doi=10.1001/jama.295.6.655}}</ref>
* No reduction in cardiovascular disease<ref name="pmid16467234">{{cite journal |author=Howard BV, Van Horn L, Hsia J, ''et al'' |title=Low-fat dietary pattern and risk of cardiovascular disease: the Women's Health Initiative Randomized Controlled Dietary Modification Trial |journal=JAMA |volume=295 |issue=6 |pages=655-66 |year=2006 |pmid=16467234 |doi=10.1001/jama.295.6.655}}</ref>
* an insignificant reduction in invasive breast cancer<ref name="pmid16467232">{{cite journal |author=Prentice RL, Caan B, Chlebowski RT, ''et al'' |title=Low-fat dietary pattern and risk of invasive breast cancer: the Women's Health Initiative Randomized Controlled Dietary Modification Trial |journal=JAMA |volume=295 |issue=6 |pages=629-42 |year=2006 |pmid=16467232 |doi=10.1001/jama.295.6.629}}</ref>
* An insignificant reduction in invasive breast cancer<ref name="pmid16467232">{{cite journal |author=Prentice RL, Caan B, Chlebowski RT, ''et al'' |title=Low-fat dietary pattern and risk of invasive breast cancer: the Women's Health Initiative Randomized Controlled Dietary Modification Trial |journal=JAMA |volume=295 |issue=6 |pages=629-42 |year=2006 |pmid=16467232 |doi=10.1001/jama.295.6.629}}</ref>
* no reductions in colorectal cancer<ref name="pmid16467233">{{cite journal |author=Beresford SA, Johnson KC, Ritenbaugh C, ''et al'' |title=Low-fat dietary pattern and risk of colorectal cancer: the Women's Health Initiative Randomized Controlled Dietary Modification Trial |journal=JAMA |volume=295 |issue=6 |pages=643-54 |year=2006 |pmid=16467233 |doi=10.1001/jama.295.6.643}}</ref>
*No reductions in colorectal cancer<ref name="pmid16467233">{{cite journal |author=Beresford SA, Johnson KC, Ritenbaugh C, ''et al'' |title=Low-fat dietary pattern and risk of colorectal cancer: the Women's Health Initiative Randomized Controlled Dietary Modification Trial |journal=JAMA |volume=295 |issue=6 |pages=643-54 |year=2006 |pmid=16467233 |doi=10.1001/jama.295.6.643}}</ref>


Additional recent [[randomized controlled trials]] have found that:
Additional recent [[randomized controlled trials]] have found that:
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:In [[young adults]] "Reducing glycemic [carbohydrate] load may be especially important to achieve weight loss among individuals with high insulin secretion."<ref name="pmid17507345">{{cite journal |author=Ebbeling CB, Leidig MM, Feldman HA, Lovesky MM, Ludwig DS |title=Effects of a low-glycemic load vs low-fat diet in obese young adults: a randomized trial |journal=JAMA |volume=297 |issue=19 |pages=2092-102 |year=2007 |pmid=17507345 |doi=10.1001/jama.297.19.2092}}</ref> This is consistent with prior studies of diabetic patients in which low carbohydrate diets were more beneficial.<ref name="pmid15148064">{{cite journal |author=Stern L, Iqbal N, Seshadri P, ''et al'' |title=The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial |journal=Ann. Intern. Med. |volume=140 |issue=10 |pages=778–85 |year=2004 |pmid=15148064 |doi=}}</ref><ref name="pmid7848401">{{cite journal |author=Garg A, Bantle JP, Henry RR, ''et al'' |title=Effects of varying carbohydrate content of diet in patients with non-insulin-dependent diabetes mellitus |journal=JAMA |volume=271 |issue=18 |pages=1421–8 |year=1994 |pmid=7848401 |doi=}}</ref>
:In [[young adults]] "Reducing glycemic [carbohydrate] load may be especially important to achieve weight loss among individuals with high insulin secretion."<ref name="pmid17507345">{{cite journal |author=Ebbeling CB, Leidig MM, Feldman HA, Lovesky MM, Ludwig DS |title=Effects of a low-glycemic load vs low-fat diet in obese young adults: a randomized trial |journal=JAMA |volume=297 |issue=19 |pages=2092-102 |year=2007 |pmid=17507345 |doi=10.1001/jama.297.19.2092}}</ref> This is consistent with prior studies of diabetic patients in which low carbohydrate diets were more beneficial.<ref name="pmid15148064">{{cite journal |author=Stern L, Iqbal N, Seshadri P, ''et al'' |title=The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial |journal=Ann. Intern. Med. |volume=140 |issue=10 |pages=778–85 |year=2004 |pmid=15148064 |doi=}}</ref><ref name="pmid7848401">{{cite journal |author=Garg A, Bantle JP, Henry RR, ''et al'' |title=Effects of varying carbohydrate content of diet in patients with non-insulin-dependent diabetes mellitus |journal=JAMA |volume=271 |issue=18 |pages=1421–8 |year=1994 |pmid=7848401 |doi=}}</ref>


====Low glycemic index====
===Low Glycemic Index===
"The glycaemic index factor is a ranking of foods based on their overall effect on blood sugar levels. Low glycaemic index foods, such as lentils, provide a slower more consistent source of glucose to the bloodstream, thereby stimulating less insulin release than high glycaemic index foods, such as white bread."<ref name="pmid17636786">{{cite journal |author=Thomas D, Elliott E, Baur L |title=Low glycaemic index or low glycaemic load diets for overweight and obesity |journal= |volume=3 |issue= |pages=CD005105 |year=2007 |pmid=17636786 |doi=10.1002/14651858.CD005105.pub2}}</ref><ref name="pmid6259925">{{cite journal |author=Jenkins DJ, Wolever TM, Taylor RH, ''et al'' |title=Glycemic index of foods: a physiological basis for carbohydrate exchange |journal=Am. J. Clin. Nutr. |volume=34 |issue=3 |pages=362-6 |year=1981 |pmid=6259925 |doi=}}</ref>
"The glycaemic index factor is a ranking of foods based on their overall effect on blood sugar levels. Low glycaemic index foods, such as lentils, provide a slower more consistent source of glucose to the bloodstream, thereby stimulating less insulin release than high glycaemic index foods, such as white bread."<ref name="pmid17636786">{{cite journal |author=Thomas D, Elliott E, Baur L |title=Low glycaemic index or low glycaemic load diets for overweight and obesity |journal= |volume=3 |issue= |pages=CD005105 |year=2007 |pmid=17636786 |doi=10.1002/14651858.CD005105.pub2}}</ref><ref name="pmid6259925">{{cite journal |author=Jenkins DJ, Wolever TM, Taylor RH, ''et al'' |title=Glycemic index of foods: a physiological basis for carbohydrate exchange |journal=Am. J. Clin. Nutr. |volume=34 |issue=3 |pages=362-6 |year=1981 |pmid=6259925 |doi=}}</ref>


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A [[meta-analysis]] by the [[Cochrane Collaboration]] concluded that low glycemic index or low glycemic load diets led to more weight loss and better lipid profiles. ''However'', the [[Cochrane Collaboration]] grouped low glycemic index and low glycemic load diets together and did not try to separate the effects of the load versus the index.<ref name="pmid17636786">{{cite journal |author=Thomas DE, Elliott E, Baur L |title=Low glycaemic index or low glycaemic load diets for overweight and obesity |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD005105 |year=2007 |pmid=17636786 |doi=10.1002/14651858.CD005105.pub2}}</ref>
A [[meta-analysis]] by the [[Cochrane Collaboration]] concluded that low glycemic index or low glycemic load diets led to more weight loss and better lipid profiles. ''However'', the [[Cochrane Collaboration]] grouped low glycemic index and low glycemic load diets together and did not try to separate the effects of the load versus the index.<ref name="pmid17636786">{{cite journal |author=Thomas DE, Elliott E, Baur L |title=Low glycaemic index or low glycaemic load diets for overweight and obesity |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD005105 |year=2007 |pmid=17636786 |doi=10.1002/14651858.CD005105.pub2}}</ref>


===Drugs===
==Drugs==
{{main|Anti-obesity drug}}
{{main|Anti-obesity drug}}


Medication most commonly prescribed for diet/exercise-resistant obesity is [[orlistat]] (Xenical, which reduces intestinal fat absorption by inhibiting [[pancreas|pancreatic]] [[lipase]]) and [[sibutramine]] (Reductil, Meridia, an [[anorectic]]). Weight loss with these drugs is modest, and over the longer term average weight loss on orlistat is 2.9 kg, sibutramine 4.2 kg and rimonabant 4.7 kg. Orlistat and rimonabant lead to a reduced incidence of diabetes, and all drugs have some effect on [[lipoprotein]]s (different forms of [[cholesterol]]). There is little data, however, on longer-term complications of obesity such as [[myocardial infarction|heart attacks]]. All drugs have side-effects and potential contraindications.<ref>{{cite journal |author=Rucker D, Padwal R, Li SK, Curioni C, Lau DC |title=Long term pharmacotherapy for obesity and overweight: updated meta-analysis |journal=BMJ |volume=335 |issue=7631 |pages=1194–9 |year=2007 |pmid=18006966 |doi=10.1136/bmj.39385.413113.25|http://www.bmj.com/cgi/content/full/335/7631/1194}}</ref> It is common for weight loss drugs to be tried for a period of time (e.g. 3 months), and to discontinue them or change to another agent if no benefit is achieved, such as weight loss less than 5% the total body weight.
==References==
 
{{Reflist|2}}
A [[meta-analysis]] of [[randomized controlled trials]] by the international [[Cochrane Collaboration]] concluded that in ''diabetic'' patients fluoxetine, orlistat and sibutramine could achieve significant but modest weight loss over 12-57 weeks, with long-term health benefits being unclear.<ref name="pmid15674929">{{cite journal |author=Norris SL, Zhang X, Avenell A, Gregg E, Schmid CH, Lau J |title=Pharmacotherapy for weight loss in adults with type 2 diabetes mellitus |journal=Cochrane database of systematic reviews (Online) |volume= |issue=1 |pages=CD004096 |year=2005 |pmid=15674929 |doi=10.1002/14651858.CD004096.pub2}}</ref>
 
Obesity may also influence the choice of drug treatment for diabetes. [[Metformin]] may lead to mild weight reduction (as opposed to [[sulfonylurea]]s and [[insulin]]), and has been demonstrated to reduce the risk of [[cardiovascular disease]] in type 2 diabetics who are obese.<ref name = UKPDS>{{cite journal | author =UK Prospective Diabetes Study (UKPDS) Group | title = Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34) | journal = Lancet | volume = 352 | issue = 9131 | pages = 854–65 | year = 1998 | pmid=9742977 |doi=10.1016/S0140-6736(98)07037-8}}</ref> The [[thiazolidinedione]]s may cause slight weight gain, but decrease the "pathologic" form of abdominal fat and may therefore be used in diabetics with central obesity.<ref>{{cite journal |author=Fonseca V |title=Effect of thiazolidinediones on body weight in patients with diabetes mellitus |journal=Am. J. Med. |volume=115 Suppl 8A |issue= |pages=42S–48S |year=2003 |pmid=14678865 |doi=10.1016/j.amjmed.2003.09.005}}</ref>


==References==
{{reflist|2}}
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[[Category:Primary Care]]
[[Category:Gastroenterology]]
[[Category:Cardiology]]
[[Category:Endocrinology]]
[[Category:Needs overview]]

Latest revision as of 16:21, 12 December 2016

Obesity Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Karol Gema Hernandez, M.D. [2]

Overview

The main treatment for obesity is to reduce body fat by eating fewer calories and exercising more. A beneficial side effect of exercise is to increase muscle, tendon, and ligament strength, which helps to prevent injury from accidents and vigorous activity. Diet and exercise programs produce an average weight loss of approximately 8% of total body mass (excluding program drop-outs). Not all dieters are satisfied with these results, but a loss of as little as 5% of body mass can create large health benefits.

Much more difficult than reducing body fat is keeping it off. Eighty to ninety-five percent of those who lose 10% or more of their body mass by dieting regain all that weight back within two to five years. The body has systems that maintain its homeostasis at certain set points, including body weight. Therefore, keeping weight off generally requires making exercise and eating right a permanent part of a person's lifestyle. Certain nutrients, such as phenylalanine, are natural appetite suppressants which allow resetting of the body's set point for body weight.

Clinical Practice Guidelines

Clinical practice guidelines are available[1][2][3][4]; however, some of the guidelines do not follow recommendations for trustworthiness by the Institute of Medicine[3][4].

2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society (DO NOT EDIT) [1]

Matching Treatment Benefits With Risk Profiles (Reduction in Body Weight Effect on CVD Risk Factors, Events, Morbidity and Mortality) (DO NOT EDIT)

Class I
"1. Counsel overweight and obese adults with CV risk factors (high BP, hyperlipidemia and hyperglycemia), that lifestyle changes that produce even modest, sustained weight loss of 3%-5% produce clinically meaningful health benefits, and greater weight losses produces greater benefits.
  • Sustained weight loss of 3%-5% is likely to result in clinically meaningful reductions in triglycerides, blood glucose, HbA1C, and the risk of developing type 2 diabetes;
  • Greater amounts of weight loss will reduce BP, improve LDL–C and HDL–C, and reduce the need for medications to control BP, blood glucose and lipids as well as further reduce triglycerides and blood glucose. (Level of Evidence: A)"

Diets for Weight Loss (Dietary Strategies for Weight Loss) (DO NOT EDIT)

Class I
"1. Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss, as part of a comprehensive lifestyle intervention. Any 1 of the following methods can be used to reduce food and calorie intake:
  • Prescribe 1,200–1,500 kcal/day for women and 1,500–1,800 kcal/day for men (kcal levels are usually adjusted for the individual’s body weight);
  • Prescribe a 500 kcal/day or 750 kcal/day energy deficit; or
  • Prescribe one of the evidence-based diets that restricts certain food types (such as high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake. (Level of Evidence: A)"
"2. Prescribe a calorie-restricted diet, for obese and overweight individuals who would benefit from weight loss, based on the patient’s preferences and health status and preferably refer to a nutrition A (Strong) professional* for counseling. A variety of dietary approaches can produce weight loss in overweight and obese adults, as presented in CQ3, ES2. (Level of Evidence: A)"

ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death - Obesity, Dieting, and Anorexia (DO NOT EDIT) [5]

Class I
"1. Life-threatening ventricular arrhythmias in patients with obesity, anorexia, or when dieting should be treated in the same manner that such arrhythmias are treated in patients with other diseases, including ICD and pacemaker implantation as required. Patients receiving ICD implantation should be receiving chronic optimal medical therapy and have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: C) "
Class III
"1. Prolonged, unbalanced, very low calorie, semistarvation diets are not recommended; they may be harmful and provoke life-threatening ventricular arrhythmias. (Level of Evidence: C)"
Class IIa
"1. Programmed weight reduction in obesity and carefully controlled re-feeding in anorexia can effectively reduce the risk of ventricular arrhythmias and SCD. (Level of Evidence: C)"

ACP 2005 Guidelines for Pharmacologic and surgical management of obesity in primary care[6]

In a clinical practice guideline by the American College of Physicians, the following five recommendations are made:[2]

  1. People with a BMI of over 30 should be counseled on diet, exercise and other relevant behavioral interventions, and set a realistic goal for weight loss.
  2. If these goals are not achieved, pharmacotherapy can be offered. The patient needs to be informed of the possibility of side-effects and the unavailability of long-term safety and efficacy data.
  3. Drug therapy may consist of sibutramine, orlistat, phentermine, diethylpropion, fluoxetine, and bupropion. For more severe cases of obesity, stronger drugs such as amphetamine and methamphetamine may be used on a selective basis. Evidence is not sufficient to recommend sertraline, topiramate, or zonisamide.
  4. In patients with BMI > 40 who fail to achieve their weight loss goals (with or without medication) and who develop obesity-related complications, referral for bariatric surgery may be indicated. The patient needs to be aware of the potential complications.
  5. Those requiring bariatric surgery should be referred to high-volume referral centers, as the evidence suggests that surgeons who frequently perform these procedures have fewer complications.

A clinical practice guideline by the US Preventive Services Task Force (USPSTF) concluded that the evidence is insufficient to recommend for or against routine behavioral counseling to promote a healthy diet in unselected patients in primary care settings, but that intensive behavioral dietary counseling is recommended in those with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians.[7][8]

Exercise

Exercise requires energy (calories). Calories are stored in body fat. The body breaks down its fat stores in order to provide energy during prolonged aerobic exercise. The largest muscles in the body are the leg muscles, and naturally these burn the most calories, which make walking, running, and cycling among the most effective forms of exercise for reducing body fat.

A meta-analysis of randomized controlled trials by the international Cochrane Collaboration found that "exercise combined with diet resulted in a greater weight reduction than diet alone".[9]

Dieting

Main article: Dieting

In general, dieting means eating less. Various dietary approaches have been proposed, some of which have been compared by randomized controlled trials:

"all 4 diets resulted in modest statistically significant weight loss at 1 year, with no statistically significant differences between diets"
"The higher discontinuation rates for the Atkins and Ornish diet groups suggest many individuals found these diets to be too extreme"

Low Carbohydrate versus Low Fat

Main article: Medical research related to low-carbohydrate diets

Many studies have focused on diets that reduce calories via a low-carbohydrate (Atkins diet, Zone diet) diet versus a low-fat diet (LEARN diet, Ornish diet). The Nurses' Health Study, an observational cohort study, found that low carbohydrate diets based on vegetable sources of fat and protein are associated with less coronary heart disease.[12]

A meta-analysis of randomized controlled trials by the international Cochrane Collaboration in 2002 concluded[13] that fat-restricted diets are no better than calorie restricted diets in achieving long term weight loss in overweight or obese people.

A more recent meta-analysis that included randomized controlled trials published after the Cochrane review[14][15][11] found that "low-carbohydrate, non-energy-restricted diets appear to be at least as effective as low-fat, energy-restricted diets in inducing weight loss for up to 1 year. However, potential favorable changes in triglyceride and high-density lipoprotein cholesterol values should be weighed against potential unfavorable changes in low-density lipoprotein cholesterol values when low-carbohydrate diets to induce weight loss are considered."[16]

The Women's Health Initiative Randomized Controlled Dietary Modification Trial[17] found that a diet of total fat to 20% of energy and increasing consumption of vegetables and fruit to at least 5 servings daily and grains to at least 6 servings daily resulted in:

  • No reduction in cardiovascular disease[18]
  • An insignificant reduction in invasive breast cancer[19]
  • No reductions in colorectal cancer[20]

Additional recent randomized controlled trials have found that:

  • The choice of diet for a specific person may be influenced by measuring the invididual's insulin secretion:
In young adults "Reducing glycemic [carbohydrate] load may be especially important to achieve weight loss among individuals with high insulin secretion."[22] This is consistent with prior studies of diabetic patients in which low carbohydrate diets were more beneficial.[23][24]

Low Glycemic Index

"The glycaemic index factor is a ranking of foods based on their overall effect on blood sugar levels. Low glycaemic index foods, such as lentils, provide a slower more consistent source of glucose to the bloodstream, thereby stimulating less insulin release than high glycaemic index foods, such as white bread."[25][26]

The glycemic load is "the mathematical product of the glycemic index and the carbohydrate amount".[27]

In a randomized controlled trial that compared four diets that varied in carbohydrate amount and glycemic index found complicated results[28]:

  • Diet 1 and 2 were high carbohydrate (55% of total energy intake)
    • Diet 1 was high-glycemic index
    • Diet 2 was low-glycemic index
  • Diet 3 and 4 were high protein (25% of total energy intake)
    • Diet 3 was high-glycemic index
    • Diet 4 was low-glycemic index

Diets 2 and 3 lost the most weight and fat mass; however, low density lipoprotein fell in Diet 2 and rose in Diet 3. Thus the authors concluded that the high-carbohydrate, low-glycemic index diet was the most favorable.

A meta-analysis by the Cochrane Collaboration concluded that low glycemic index or low glycemic load diets led to more weight loss and better lipid profiles. However, the Cochrane Collaboration grouped low glycemic index and low glycemic load diets together and did not try to separate the effects of the load versus the index.[25]

Drugs

Main article: Anti-obesity drug

References

  1. ↑ 1.0 1.1 Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, Donato KA; et al. (2013). "2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society". Circulation. doi:10.1161/01.cir.0000437739.71477.ee. PMID 24222017.
  2. ↑ 2.0 2.1 Snow V, Barry P, Fitterman N, Qaseem A, Weiss K, Clinical Efficacy Assessment Subcommittee of the American College of Physicians (2005). "Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians". Ann Intern Med. 142 (7): 525–31. PMID 15809464.
  3. ↑ 3.0 3.1 Garvey WT, Garber AJ, Mechanick JI, Bray GA, Dagogo-Jack S, Einhorn D; et al. (2014). "American association of clinical endocrinologists and american college of endocrinology consensus conference on obesity: building an evidence base for comprehensive action". Endocr Pract. 20 (9): 956–76. doi:10.4158/EP14279.CS. PMID 25253226.
  4. ↑ 4.0 4.1 Yumuk V, Tsigos C, Fried M, Schindler K, Busetto L, Micic D; et al. (2015). "European Guidelines for Obesity Management in Adults". Obes Facts. 8 (6): 402–24. doi:10.1159/000442721. PMID 26641646.
  5. ↑ Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M; et al. (2006). "ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". Circulation. 114 (10): e385–484. doi:10.1161/CIRCULATIONAHA.106.178233. PMID 16935995.
  6. ↑ Snow V, Barry P, Fitterman N, Qaseem A, Weiss K (2005). "Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians". Ann Intern Med. 142 (7): 525–31. PMID 15809464. Fulltext.
  7. ↑ "Behavioral counseling in primary care to promote a healthy diet: recommendations and rationale". Retrieved 2007-05-22.
  8. ↑ Pignone MP, Ammerman A, Fernandez L; et al. (2003). "Counseling to promote a healthy diet in adults: a summary of the evidence for the U.S. Preventive Services Task Force". American journal of preventive medicine. 24 (1): 75–92. PMID 12554027.
  9. ↑ Shaw K, Gennat H, O'Rourke P, Del Mar C (2006). "Exercise for overweight or obesity". Cochrane database of systematic reviews (Online) (4): CD003817. doi:10.1002/14651858.CD003817.pub3. PMID 17054187.
  10. ↑ Truby H, Baic S, deLooy A; et al. (2006). "Randomised controlled trial of four commercial weight loss programmes in the UK: initial findings from the BBC "diet trials"". BMJ. 332 (7553): 1309–14. doi:10.1136/bmj.38833.411204.80. PMID 16720619.
  11. ↑ 11.0 11.1 Dansinger ML, Gleason JA, Griffith JL, Selker HP, Schaefer EJ (2005). "Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial". JAMA. 293 (1): 43–53. doi:10.1001/jama.293.1.43. PMID 15632335.
  12. ↑ Halton TL, Willett WC, Liu S; et al. (2006). "Low-carbohydrate-diet score and the risk of coronary heart disease in women". N. Engl. J. Med. 355 (19): 1991–2002. doi:10.1056/NEJMoa055317. PMID 17093250.
  13. ↑ Pirozzo S, Summerbell C, Cameron C, Glasziou P (2002). "Advice on low-fat diets for obesity". Cochrane database of systematic reviews (Online) (2): CD003640. PMID 12076496.
  14. ↑ Samaha FF, Iqbal N, Seshadri P; et al. (2003). "A low-carbohydrate as compared with a low-fat diet in severe obesity". N. Engl. J. Med. 348 (21): 2074–81. doi:10.1056/NEJMoa022637. PMID 12761364.
  15. ↑ Foster GD, Wyatt HR, Hill JO; et al. (2003). "A randomized trial of a low-carbohydrate diet for obesity". N. Engl. J. Med. 348 (21): 2082–90. doi:10.1056/NEJMoa022207. PMID 12761365.
  16. ↑ Nordmann AJ, Nordmann A, Briel M; et al. (2006). "Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials". Arch. Intern. Med. 166 (3): 285–93. doi:10.1001/archinte.166.3.285. PMID 16476868.
  17. ↑ Howard BV, Manson JE, Stefanick ML; et al. (2006). "Low-fat dietary pattern and weight change over 7 years: the Women's Health Initiative Dietary Modification Trial". JAMA. 295 (1): 39–49. doi:10.1001/jama.295.1.39. PMID 16391215.
  18. ↑ Howard BV, Van Horn L, Hsia J; et al. (2006). "Low-fat dietary pattern and risk of cardiovascular disease: the Women's Health Initiative Randomized Controlled Dietary Modification Trial". JAMA. 295 (6): 655–66. doi:10.1001/jama.295.6.655. PMID 16467234.
  19. ↑ Prentice RL, Caan B, Chlebowski RT; et al. (2006). "Low-fat dietary pattern and risk of invasive breast cancer: the Women's Health Initiative Randomized Controlled Dietary Modification Trial". JAMA. 295 (6): 629–42. doi:10.1001/jama.295.6.629. PMID 16467232.
  20. ↑ Beresford SA, Johnson KC, Ritenbaugh C; et al. (2006). "Low-fat dietary pattern and risk of colorectal cancer: the Women's Health Initiative Randomized Controlled Dietary Modification Trial". JAMA. 295 (6): 643–54. doi:10.1001/jama.295.6.643. PMID 16467233.
  21. ↑ Gardner CD, Kiazand A, Alhassan S; et al. (2007). "Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial". JAMA. 297 (9): 969–77. doi:10.1001/jama.297.9.969. PMID 17341711.
  22. ↑ Ebbeling CB, Leidig MM, Feldman HA, Lovesky MM, Ludwig DS (2007). "Effects of a low-glycemic load vs low-fat diet in obese young adults: a randomized trial". JAMA. 297 (19): 2092–102. doi:10.1001/jama.297.19.2092. PMID 17507345.
  23. ↑ Stern L, Iqbal N, Seshadri P; et al. (2004). "The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial". Ann. Intern. Med. 140 (10): 778–85. PMID 15148064.
  24. ↑ Garg A, Bantle JP, Henry RR; et al. (1994). "Effects of varying carbohydrate content of diet in patients with non-insulin-dependent diabetes mellitus". JAMA. 271 (18): 1421–8. PMID 7848401.
  25. ↑ 25.0 25.1 Thomas D, Elliott E, Baur L (2007). "Low glycaemic index or low glycaemic load diets for overweight and obesity". 3: CD005105. doi:10.1002/14651858.CD005105.pub2. PMID 17636786.
  26. ↑ Jenkins DJ, Wolever TM, Taylor RH; et al. (1981). "Glycemic index of foods: a physiological basis for carbohydrate exchange". Am. J. Clin. Nutr. 34 (3): 362–6. PMID 6259925.
  27. ↑ Brand-Miller JC, Thomas M, Swan V, Ahmad ZI, Petocz P, Colagiuri S (2003). "Physiological validation of the concept of glycemic load in lean young adults". J. Nutr. 133 (9): 2728–32. PMID 12949357.
  28. ↑ McMillan-Price J, Petocz P, Atkinson F; et al. (2006). "Comparison of 4 diets of varying glycemic load on weight loss and cardiovascular risk reduction in overweight and obese young adults: a randomized controlled trial". Arch. Intern. Med. 166 (14): 1466–75. doi:10.1001/archinte.166.14.1466. PMID 16864756.

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