Obesity medical therapy: Difference between revisions
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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> | ||
===ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (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>=== | |||
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]] | |||
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| 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> | |||
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIa]] | |||
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|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> | |||
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=== Dieting === | === Dieting === | ||
Revision as of 11:23, 30 October 2012
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Obesity Microchapters |
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Diagnosis |
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Treatment |
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Lifestyle Intervention and Counseling (Comprehensive Lifestyle Intervention) |
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Case Studies |
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USPSTF Recommendations and Guidelines on Management of Obesity |
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2017 Guidelines for Screening of Obesity in Children and Adolescents |
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AHA/ACC/TOS Guidelines on Management of Overweight and Obesity |
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2013 AHA/ACC/TOS Guidelines on Management of Overweight and Obesity |
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Obesity medical therapy On the Web |
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American Roentgen Ray Society Images of Obesity medical therapy |
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Risk calculators and risk factors for Obesity medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Medical Therapy
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 Protocols
In a clinical practice guideline by the American College of Physicians, the following five recommendations are made:[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.
- 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.
- 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.
- 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.
- 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.[2][3]
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".[4]
ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (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 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)" |
Dieting
In general, dieting means eating less. Various dietary approaches have been proposed, some of which have been compared by randomized controlled trials:
- A comparison of Dr. Atkins', Slim-Fast's, Weight Watchers', and Rosemary Conley's diets found no significant differences.[6]
- A comparison of Atkins diet, Zone diet, Weight Watchers, and Ornish diet noted:[7]
- "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
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.[8]
A meta-analysis of randomized controlled trials by the international Cochrane Collaboration in 2002 concluded[9] 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[10][11][7] 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."[12]
The Women's Health Initiative Randomized Controlled Dietary Modification Trial[13] 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[14]
- an insignificant reduction in invasive breast cancer[15]
- no reductions in colorectal cancer[16]
Additional recent randomized controlled trials have found that:
- A comparison of Atkins, Zone diet, Ornish diet, and LEARN diet in premenopausal women found the greatest benefit from the Atkins diet.[17]
- 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."[18] This is consistent with prior studies of diabetic patients in which low carbohydrate diets were more beneficial.[19][20]
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."[21][22]
The glycemic load is "the mathematical product of the glycemic index and the carbohydrate amount".[23]
In a randomized controlled trial that compared four diets that varied in carbohydrate amount and glycemic index found complicated results[24]:
- 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.[21]
Drugs
Medication most commonly prescribed for diet/exercise-resistant obesity is orlistat (Xenical, which reduces intestinal fat absorption by inhibiting 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 lipoproteins (different forms of cholesterol). There is little data, however, on longer-term complications of obesity such as heart attacks. All drugs have side-effects and potential contraindications.[25] 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.
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.[26]
Obesity may also influence the choice of drug treatment for diabetes. Metformin may lead to mild weight reduction (as opposed to sulfonylureas and insulin), and has been demonstrated to reduce the risk of cardiovascular disease in type 2 diabetics who are obese.[27] The thiazolidinediones may cause slight weight gain, but decrease the "pathologic" form of abdominal fat and may therefore be used in diabetics with central obesity.[28]
References
- ↑ 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.
- ↑ "Behavioral counseling in primary care to promote a healthy diet: recommendations and rationale". Retrieved 2007-05-22.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 7.0 7.1 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 21.0 21.1 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Rucker D, Padwal R, Li SK, Curioni C, Lau DC (2007). "Long term pharmacotherapy for obesity and overweight: updated meta-analysis". BMJ. 335 (7631): 1194–9. doi:10.1136/bmj.39385.413113.25. PMID 18006966. Text "http://www.bmj.com/cgi/content/full/335/7631/1194" ignored (help)
- ↑ Norris SL, Zhang X, Avenell A, Gregg E, Schmid CH, Lau J (2005). "Pharmacotherapy for weight loss in adults with type 2 diabetes mellitus". Cochrane database of systematic reviews (Online) (1): CD004096. doi:10.1002/14651858.CD004096.pub2. PMID 15674929.
- ↑ UK Prospective Diabetes Study (UKPDS) Group (1998). "Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34)". Lancet. 352 (9131): 854–65. doi:10.1016/S0140-6736(98)07037-8. PMID 9742977.
- ↑ Fonseca V (2003). "Effect of thiazolidinediones on body weight in patients with diabetes mellitus". Am. J. Med. 115 Suppl 8A: 42S–48S. doi:10.1016/j.amjmed.2003.09.005. PMID 14678865.