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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Other medications that have been used include phentermine, ephedra, dexfenfluramine, phenyl-propanolamine (PPA), and mazindol.^1,2 All of these medications produce significant weight loss in the short term (SOR: A), but they are not indicated for long-term use.² In fact, phenylpropanolamine and dexfenfluramine are no longer available because of their severe side effects.² Antidepressants do not yield a consistent benefit in well-designed studies of obesity management.²

Table 3 summarizes the effects of medications on weight loss.

Surgery

Surgical management of obesity is reserved for extremely obese persons because of the significant morbidity and mortality associated with the interventions. Currently, gastric bypass procedures result in less than 1% perioperative mortality and about 10% perioperative morbidity.⁴¹ Patients with a BMI >40 (or >37 with weight-related comorbidities) are candidates for surgery.⁴²

It has been estimated that, for these patients, the cost per pound lost is less with surgery than with medications.⁴³ In most series, the average morbidly obese patient can expect to lose 50% of excess body weight at 5 years after bypass surgery, and 50% of excess weight will be lost even 10 years post-operatively (SOR: B).⁴⁴

Several options are available for surgical management of obesity. While the technical aspects of surgery are beyond the scope of this article, some generalizations can be made. Procedures may reduce the size of the stomach to decrease the volume of intake (gastroplasty), or may create a malabsorption condition (intestinal bypass) to decrease absorption of calories. The combination of a restrictive procedure with malabsorption (Rouxen-Y gastic bypass) is superior to a restrictive procedure alone (SOR: B).⁴⁴

The surgical management of morbid obesity improves quality of life for patients,⁴³ but no published studies to date have been able to evaluate the effect of the surgical management on mortality in the morbidly obese patient.

Complementary and alternative therapies

In addition to the traditional methods of weight loss, acupuncture and hypnosis have been studied in the treatment of obesity. Acupuncture does not appear to have any benefit greater than placebo (SOR: B).⁴⁵ Hypnosis has also been reviewed and likely adds little, if any, benefit beyond that of placebo (SOR: B).⁴⁵ Most studies of both acupuncture and hypnosis suffer from the difficulties of performing adequate control groups, and meta-analyses have demonstrated mixed results.^45,46

Maintenance programs

There is significant evidence that when patients discontinue effective weight loss interventions (eg, diet or behavioral modification) they will return to their baseline weight. Because of this, it is important to consider maintenance programs as part of overall treatment and to imbue in patients the expectation that treatment will be lifelong. Examples of an approach to maintenance therapy include attendance at regular exercise or therapy sessions even after achieving weight-loss goals, or continued participation at commercial weight-loss program meetings or support groups.

ACKNOWLEDGEMENTS

The author was supported by grant 1 D45 PE 50175 -01, “Faculty Development in Family Medicine” funded by Health Resources and Services Administration (HRSA). The author wishes to thank Bill Hueston, MD, Peter Carek, MD, Arch Mainous III, PhD, and Lori Dickerson, PharmD, for their help with manuscript review. The author wishes to thank Tara Hogue for her for help with the preparation of this manuscript.