Effective management of obesity

,

Applied Evidence

Effective management of obesity

J Fam Pract. 2003 January;52(1):34-42

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References

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18. Flier JS, Foster DW. Eating Disorders: Obesity, anorexia nervosa, and bullemia nervosa. In: Wilson JD, Foster DW, Kronenberg HM, Larsen PR, eds. Williams Textbook of Endocrinology. 9th ed. Philadelphia, Pa: WB Saunders; 1998;1051-97.

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Lifestyle modifications

Management of obesity in every case should include dietary changes, exercise, and behavioral modification.

Dietary changes. Diets create a caloric deficit by reducing the intake of calories. Average weight loss with low-calorie diets is approximately 8% at 3–12 months (SOR: A),⁵ with most of the loss occurring in the first 3–5 months.²⁴ There are many kinds of diets for weight loss, including low calorie, very-low calorie, low fat, very low fat, and low carbohydrate, but long-term compliance with all types of dietary interventions is a significant problem. When diet alone is used as therapy, between one third and one half of weight loss will not be maintained.²⁴ Emerging strategies to help improve dietary compliance include behavioral modification (see below) and meal substitutes. Recent reports of interventions such as meal-replacement shakes indicate that long-term weight loss can be significantly improved (SOR: B).^25-27

Examples of low-calorie, nutritionally balanced diets are Weight Watchers, Jenny Craig, Nutrisystem, the National Cholesterol Education Program Step I and Step II diets, and the Dietary Approaches to Stop Hypertension (DASH) diet. Low-calorie diets provide 800–1500 kilocalories per day.^5,28,29 Very-low-calorie diets (400–500 kilocalories per day) may increase rates of weight loss initially, but at 1 year, results are similar to those of low-calorie diets (SOR: A).^5,30

A low-fat diet (fat content 10%–19%) without a decrease in total calorie intake does not promote weight loss (SOR: A).^5,31 Very-low-fat diets containing less than 10% fat have been described by such authors as Ornish and Pritikin.²⁵ Obese patients using either the low-fat or very-low-fat diet can lose body weight and body fat, but only if calories are also decreased (SOR: A).^5,28

Low-carbohydrate diets, such as Dr Atkin’s diet, are associated with modest (approximately 5 kg, or 11 lbs) weight loss (SOR: C).^28,32 Improved study design is required to further evaluate the effectiveness and safety of low-carbohydrate diets in the clinical setting.

Exercise. Most studies of exercise are based on 30–50 minutes of moderately intense aerobic exercise, repeated 3–7 times per week.⁵ When it is the only prescribed therapy, exercise can be expected to produce modest weight loss only (SOR: A).^5,33 Exercise combined with dietary intervention, however, increases weight lost (SOR: A), and exercise by itself may prevent weight gain (SOR: C).⁵

Behavioral Modification. Behavioral modification has been evaluated in combination with diet or exercise, and has been shown to increase compliance and weight loss for durations of 1 year or less (SOR: A).^5,34 Weight gain is common when therapy is discontinued, and at 5 years, there is no difference between those who received behavioral therapy and those who were in control groups (SOR: A).⁵

Medications

Medications for treatment of obesity act through 1 or more of 3 mechanisms:

Appetite suppression (eg, sibutramine, antidepressants such as fluoxetine)
Increased metabolic activity (eg, stimulants such as ephedra with caffeine, Β-3 agonists)
Decreased absorption of caloric load (orlistat)

For mild-to-moderate obesity (BMI >30 and <40), medications can be beneficial (SOR: A), but long-term weight loss beyond 2 years has not been studied.³⁵ Pharmacologic intervention without lifestyle intervention actually decreases a person’s ability to lose weight (SOR: B).³⁶

Two medications are approved by the United States Food and Drug Administration for long-term obesity management: sibutramine and orlistat. Both drugs reduce weight modestly (SOR: A).^37-39 Both medications have similar indications for use: BMI >30, or BMI >27 with the presence of other cardiovascular risk factors (ie, diabetes or hyperlipidemia). Both should be used in conjunction with reduced-calorie diet and exercise (SOR: B).³⁶

Sibutramine is usually started at 10 mg once a day, given with or without food. The dose may be titrated to a maximum of 15 mg/d after 4 weeks if weight loss has been inadequate.¹ Sibutramine is known to increase pulse rate and blood pressure in a significant number of patients; because of this, regular evaluation of vital signs is required. At present, long-term use of sibutramine cannot be recommended, and safety data are unavailable beyond 1 year of use. Sibutramine should be avoided if these conditions are present: hypertension, coronary heart disease, congestive heart failure, an arrhythmic condition, pregnancy, renal impairment, concomitant use of MAOI, or a history of stroke.

Orlistat is started at 120 mg three times a day, and is taken with meals that contain fat. It may still be effective if taken up to one hour after eating. Orlistat may be avoided if the meal contains no fat. This drug may interfere with the absorption of some fat-soluble vitamins, and it is therefore recommended that patients take a multivitamin that has fat-soluble vitamins at least 2 hours before or after ingesting orlistat. Orlistat is not absorbed into the body and, at this time, no laboratory follow-up is needed. Regular evaluation of weight is needed to assess the efficacy of treatment. Orlistat should be avoided by those who have cholestasis or malabsorptive disorders or by those taking cyclosporine.⁴⁰