2. Treatment options
When does obesity threaten the health
and life of a patient?
Which patients have co-morbidities
that make an aggressive treatment
necessary?
2012 2
3. Steps in determining treatment
Determine BMI.
Assess complications and risk factors
2012 3
4. Steps in determining treatment
Determine BMI-related health risk
Determine weight reduction
exclusions
Mental illness
Unstable medical condition
Some medications
Temporary
Pregnancy or lactation
2012 4
5. Steps in determining treatment
Possible exclusions
Osteoporosis
BMI in minimal or no-risk category
History of mental illness
Medications
Permanent exclusions
Anorexia nervosa
Terminal illness
Assess patient readiness
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6. Steps in determining treatment
Treatment Options
1. Mild energy-deficit regimen
Diet, diet and exercise, behavioral therapy
2. Aggressive energy-deficit regimen
VLCD
Extensive exercise program
3. Obesity drugs
4. Surgery More extreme
options
2012 6
7. Dietary treatment
When someone is a few pounds overweight
and is motivated to lose weight, dietary
approach is a safe and effective method for
weight loss. It is also the best method for
helping to acquire new skills for maintaining
a weight loss.
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8. Dieting with the Exchange List
The Exchange diet.
Monitor intake of carbohydrates, fat
and protein as well as portion sizes.
Includes foods from each group and
can be used indefinitely.
It also works well in weight
maintenance.
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9. Dieting with the Exchange List
Foods are divided into 6 categories:
Starch/Bread
Meat
Vegetables
Fruit
Milk
Fat
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10. The Exchange List
The number of exchanges is
determined by the total number of
calories required.
Different for each person and
depends on:
height, weight, and energy expenditure.
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12. Example of daily exchange diet: 1800
Kcals daily
BREAKFAST
1 c orange juice 2 Fruits
2 slices of toast 2 Breads
1 hard-cooked egg Yields 1 Meat
2 tsp margarine 2 Fat
1 c 2% milk 1 Milk
Coffee or tea Free Food
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13. Example of daily exchange diet: 1800
Kcals daily
LUNCH
½ c tuna 2 Meat
2 slices whole wheat bread 2 Bread
½ c tomato slices 1 Vegetable
Lettuce/cucumber salad Raw Vegetable
Yields
1 c sliced peaches 2 Fruit
1 tsp margarine 2 Fat
Tea with lemon Free Foods
2012 13
14. Example of daily exchange diet: 1800
Kcals daily
3 oz baked chicken DINNER 3 meat
½ c mashed potato 1 Bread
1 small whole grain roll 1 Bread
½ c broccoli, ½ c carrots 1 Vegetable
Yields
Tossed salad Raw Vegetable
1 Tbsp salad dressing 1 Fat
1 tsp margarine 1 Fat
Coffee Free Food
2012 14
15. Example of daily exchange diet: 1800
Kcals daily
EVENING
SNACK
2 graham crackers 1 Bread
1 c 2% milk 1 Milk
2012 15
16. The Exchange Diet
For more information please visit:
http://www.diabetes.org/home.jsp
2012 16
17. Dieting Using Calorie Controlled
Portions
MEAL REPLACEMENT PLAN
Liquid formula or a packaged item
Fixed number of calories to replace a meal.
Control portion sizes
Fat, carbohydrate, calories
Balanced meals
2012 17
18. Meal Replacement Plan
4 types of meal replacers:
Powder mixes
Shakes
Bars
Prepackaged Meals
2012 18
19. Meal Replacement Plan
An intake of five fruits and vegetables is
recommended.
Effective
Convenient
Nutritionally balanced
2012 19
20. Example:
A MEAL REPLACEMENT PLAN
Breakfast Meal Replacement
Lunch Sensible Meal or Meal
Replacement
Dinner Sensible Meal
Snacks Fruit, vegetable, fat-
free yogurt or cheese,
nuts, pretzels, or air-
popped popcorn
2012 20
21. Exercise
Adults: 30-45 minutes of exercise three to five days
each week
Include 5-10 minute warm up and cool down
Weight loss: at least 30 minutes of aerobic activity a
day for five days
2012 21
22. Exercise
Energy Balance = maintaining
weight.
Positive energy balance leads to
weight gain.
Negative energy balance leads to
weight loss.
2012 22
23. Exercise: Benefits
Exercise builds lean body mass.
Walking, running and doing physical activity
can burn two to three times more calories
than similar amount of time sitting.
With exercise there is an improvement in
overall physical fitness.
Exercise improves maintenance of weight after
weight loss.
2012 23
24. Exercise
For Weight Loss
150 to 200 minutes of moderate physical activity
each week
diet for weight loss
For Improved Health
An exercise program with less than 150 minutes a
week and lower intensity can result in improvement
in cardio-respiratory fitness.
2012 24
25. Aerobic Activity
Aerobic exercise is any extended activity that makes the
lungs and heart work harder while using the large muscle
groups in the arms and legs at a regular, even pace.
EXAMPLES
Brisk walking
Jogging
Bicycling Racket sports
Swimming Lawn mowing
Aerobic dancing Ice or roller skating
Using aerobic equipment
(treadmill, stationary bike)
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26. Anaerobic Activity
Anaerobic activity is short bursts of very
strenuous activity using large muscle groups
(Ex: weight lifting, curls, power lifting).
Helps build and tone muscles, but it does not
benefit the heart or the lungs.
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27. Very Low Calorie Diets (VLCD)
Formula diet of 800 calories or less.
Must be under proper medical
supervision.
Produce significant weight loss in
moderately to severely obese patients.
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28. VLCD: Facts
Not recommended for pregnant or breastfeeding
women
Not appropriate for children or adolescents
Not recommended for older individuals
2012 28
29. Behavioral Treatment
Widely used strategy
Based on adjusting energy balance
Individual treatment, or
Group Format
(Around 18-24 weeks)
One of the most successful
treatment programs
2012 29
30. Group Approaches
Social support
integration into social network and positive
interactions with others.
Individual feels support, acceptance, and
encouragement by others.
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31. Behavior Treatment
Need to change one’s approach
thinking
feelings
actions
to eating and physical activity.
2012 31
32. Behavioral targets
Total energy _ Total energy
Weight = intake expenditure
Eating Activity
Targets of behavioral therapy
2012 32
34. Behavior Therapy:
Important Components
3. Setting Goals
Calories, fat, physical activity.
Short-term goal of losing 1 to 2 pounds a week.
Choose specific, attainable, and realistic goals.
Have a long-term goal.
2012 34
35. Behavior Therapy:
Important Concepts
4. Keeping Track of Eating and Exercising
Tracking to raise awareness.
Self monitoring.
Record time, activating event, place and quantity of
eating, and activity behaviors.
2012 35
37. Behavior Therapy:
Important Concepts
Techniques to conquer eating triggers include:
eating regular meals
eating at the same time and place
use smaller plates
keeping accessible food out of sight
eating only when hungry
avoiding activities that encourage eating
2012 37
38. Behavior Therapy:
Important Concepts
6. Changing Eating and Activity Patterns
slowing pace of eating
reducing portion sizes
measuring food intake
leaving food on plate
improving food choices
eliminating second servings
2012 38
39. Behavior Therapy:
Important Concepts
Changing Eating and Activity Patterns
Programmed exercise vs lifestyle
Lifestyle activity preferable for weight
loss.
2012 39
40. Behavior Therapy:
Important Concepts
7. Contingency Management
Positive reinforcement (reward)
An effective reward - immediate, desirable, and given
based on meeting a specific goal.
Tangible rewards - a new CD
Intangible reward – taking time off
2012 40
41. Behavior Therapy:
Important Concepts
8. Cognitive Behavioral Strategies
Traditional behavioral treatment components
with emphasis on thinking patterns that may
affect eating behaviors.
2012 41
42. Behavior Therapy:
Important Concepts
9. Stress Management
Stress is a primary predictor of
overeating and relapse.
Stress management skills
2012 42
43. Drug Treatment of Obesity:
Indicated when
BMI is greater than 30
BMI is higher than 27 and there are
other cardiovascular complications
After several attempts diet alone is
not enough
Cardiovascular complications include:
Hypertension, Dyslipidemia, Coronary Heart
Disease, Type 2 Diabetes, and Sleep Apnea
2012 43
44. Drug Therapy
Commonly prescribed drugs for the
treatment of obesity include:
Phentermine
Sibutramine
Orlistat
2012 44
45. Drug Therapy: Phentermine
Brand names are Adipex-P, Obenix, Oby-Trim
Most commonly prescribed medication for weight
loss.
Phentermine increases norepinephrine, a
neurotransmitter in the brain that decreases
appetite.
Phentermine has stimulant properties, and it may
cause high blood pressure or irregular heat beats.
2012 45
46. Drug Therapy: Sibutramine
The brand name is Meridia
Sibutramine induces weight loss by reducing food intake.
It stimulates the
satiety centers in the brain.
Sibutramine use may increase heart rate and blood
pressure.
Sibutramine is not recommended for someone with
uncontrolled hypertension, tachycardia, or serious
heart, liver, or kidney disease.
2012 46
47. Drug Therapy: Orlistat
The Brand name is Xenical
Orlistat prevents the digestion of dietary fat.
Bowel habits will likely change.
Leads to improvement in blood lipids.
Multivitamin supplement is encouraged.
2012 47
48. Surgical Treatment of Obesity
Criteria used for surgical treatment:
BMI is 40 or higher
BMI of 35-39.9 and a serious obesity-related
health problem
such as: Type 2 diabetes, hypertension, heart
disease, or sleep apnea
2012 48
49. Types of GI surgeries available
Restrictive
Malabsorptive
Combined restrictive/malabsorptive
2012 49
50. GI Surgeries: Restrictive
Purely restrictive operations only limit food intake and
do not interfere with the normal digestive process.
Create a pouch.
Delay in food emptying.
2012 50
52. Restrictive Operations: Examples
2. Vertical banded gastroplasty.
Uses the band and staples to create
a small pouch. Not commonly used
today.
2012 52
53. Restrictive Operations: Advantages
1. Generally safer than malabsorptive
procedures.
2. Done via laparoscopy allowing for
smaller incisions.
3. Surgeries can be reversed if necessary.
4. Result in few nutritional deficiencies.
2012 53
54. Restrictive Operations:
Disadvantages
1. Smaller weight loss.
2. Can lead to weight gain over time.
3. No change in eating habits.
4. Success depends on the patient’s
willingness to adopt a healthy lifestyle.
2012 54
55. Restrictive Operations: Risks
1. Overeating can lead to vomiting.
2. Break in tubing.
3. Problems leading to a second operation.
These risks need to be taken into account
by any individual considering the
surgery!
2012 55
56. Malabsorptive Operations
The main malabsorptive operation is the
jejunoileal bypass which is not
performed today because of the high
incidence of health complications.
2012 56
57. Combined Restrictive and Malabsorptive
Operations
Restricts both food intake and the amount of
calories and nutrients the body absorbs.
Roux-en-Y gastric bypass (RGB)
Creates a pouch.
Connects the small intestine
to the pouch, bypassing large
sections of the intestines.
2012 57
58. Combined Restrictive and
Malabsorptive Operations
Biliopancreatic diversion (BPD)
Remove portion of stomach.
Connect this directly to the
final segment of the small intestine
completely bypassing sections of
intestines.
2012 58
59. Combined Operations: Advantages
1. Rapid weight loss.
2. Maintain good weight loss for 10 years or
more.
3. Can lose up to 75-80% of excess weight.
4. May lead to greater improvement in
health.
2012 59
60. Combined Operations: Disadvantages
1. Can be difficult.
2. May result in long-term nutritional
deficiencies.
3. Decreased absorption of iron and calcium.
4. Requires fat soluble vitamin
supplementation.
5. May have dumping syndrome.
2012 60
61. Combined Operations: Risks
1. May lead to complications.
2. Greater risk for abdominal hernias.
3. The risk of death may be higher.
2012 61
62. Bariatric Surgery: Facts
Procedures cost from $17,000 to $35,000.
Medical insurance coverage varies by state.
2012 62
63. NIDDK
(National Institute of Diabetes and Digestive and Kidney
Diseases)
The patient should consider the following
questions prior to weight loss surgery:
1. Are you unlikely to lose weight or keep weight
off long-term with non-surgical measures?
2. Are you well informed about the surgical
procedure and the effects of treatment?
3. Are you determined to lose weight and
improve your health?
2012 63
64. NIDDK
4. Are you aware of how your life may change
after the operation?
5. Are you aware of the potential for serious
complications, dietary restrictions, and
occasional failures?
6. Are you committed to lifelong medical follow-
up and vitamin/mineral supplementation?
2012 64
65. Conclusions
When there are no complications or co-
morbidities associated with obesity,
dietary, exercise and behavioral
approaches are the safest and best
approaches and can lead to long term
successful weight loss.
For successful weight loss to become
permanent, an individual has to adopt new
and permanent eating and exercise
behaviors.
2012 65
66. Conclusion
It is very important for individuals considering
weight loss drug therapy or surgeries to be well
aware of the risks associated with the
treatments.
Once all risks are understood, then ultimately it
is the individual’s decision whether to go along
with the treatment.
2012 66
67. References: Behavior Therapy and
VLCD Information
http://www.medhelp.org/NIHlib/GF-390.html
Foreyt, J.P., & Poston, W.S.C., Jr. (1998a). The role of the
behavioral counselor in obesity treatment. J Am Diet Assoc,
10(Supplement 2), S27-S30
Foreyt, J.P., & Poston, W.S.C., Jr. (1998b). What is the role of
cognitive-behavior therapy in patient management? Obes Res,
6(Supplement 1), 18S-22S
Foster, G.D., Wadden, T.A., Vogt, R.A., & Brewer, G. (1997).
What is a reasonable weight loss? Patients' expectations and
evaluations of obesity treatment outcomes. J Consult Clin
Psychol, 65, 79-85
2012 67
68. References : Behavior therapy
Poston, W.S.C., Jr., Hyder, M.L., O'Byrne, K.K., & Foreyt,
J.P. (2000). Where do diets, exercise, and behavior
modification fit in the treatment of obesity? Endocrine,
13(2), 187-192.
Wadden, T.A., Sarwer, D.B., & Berkowitz, R.I. (1999).
Behavioural treatment of the overweight patient. Baillieres
Best Pract Res Clin Endocrinol Metab, 13(1), 93-107.
Wing, R.R. (1993). Behavioral approaches to the
treatment of obesity. In G. Bray, C. Bouchard & P. James
(Eds.), Handbook of Obesity (pp. 855-873). New York:
Marcel Dekker, Inc.
Wing, R.R., & Tate, D.F. (2002). Behavior modification for
obesity. In J.F. Caro (Ed.), Obesity.
http://www.endotext.org/obesity/index.htm:
2012 68
69. Sites: Drug Therapy Info & Surgery
http://www.cdc.gov
National Heart, Lung, and Blood Institute, Clinical Guidelines
on the Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults, 1998.
Astrup A, Hansen DL, Lundsgaard C, Toubro S. Sibutramine
and energy balance. Int J Obes Relat Metab Disord 1998
Aug; 22 Suppl 1: S30-S35.
Bray GA, Ryan DH, Gordon D, et al. A double-blind
randomized placebo-controlled trial of sibutramine. Obes Res
1996 May; 4(3): 263-70.
Heal DJ, Aspley S, Prow MR, et al. Sibutramine: a novel anti-
obesity drug. A review of the pharmacological evidence to
differentiate it from d-amphetamine and d-fenfluramine. Int J
Obes Relat Metab Disord 1998 Aug; 22 Suppl 1: S18-S29.
2012 69
70. References: Drug therapy & Surgery
www.meridia.net
Waitman, JA, Aronne LJ. Phrmacotherpay of obesity.
Obesity Management 1: 15-19, 2005.
Greenway, F. Surgery for obesity. Endocrinology and
Metabolism Clinics of North America 25(4):1005-1027.
Surgery for morbid obesity: What patients should know. 3rd
Ed. American Society for BariatricSurgery, Gainesville, FL
2001.
http://win.niddk.nih.gov/publications/gastric.htm
Escott-Stump, S. Nutrition and Diagnosis-Related Care. 5th
Edition. 2002.
70
2012
71. References: Exercise
http://www.cdc.gov
Ross R, Jansses I, Dawson J, Kungl A-M, Kuk JL, Wong SL,
Nguyen-Day T-B, Lee SL, Kilpatrick K, Hudson R. Exercise
induced reduction in obesity and insulin resistance in women: a
randomized controlled trial. Obesity Research 12:789-798, 2004.
Jakicic JM, Marcus BH, Gallagher KI, Napolitano M, Lang W.
Effects of exercise duration and intensity on weight loss in
overweight, sedentary women. JAMA 10: 1323-1330, 2003.
Ross R, Katzmarzyk PT. Cardio respiratory fitness is associated
with diminished total and abdominal obesity independent of body
mass index. International Journal of Obesity 27: 204-210, 2003.
McArdle WD, Katch FL, and Katch VL. Exercise Physiology:
Energy, Nutrition and Human Performance, 5th Edition. Lippincott
Williams & Wilkins 2004.
2012 71
72. References: Diet
http://www.cdc.gov
Noakes M, Foster PR, Keogh JB, Clifton PM. Meal replacements
are as effective as structured weight-loss diets for treating obesity in
adults with features of metabolic syndrome. J Nutr. 2004
Aug;134(8):1894-9.
Truby H, Millward D, Morgan L, Fox K, Livingstone MB, DeLooy A,
Macdonald I. A randomised controlled trial of 4 different commercial
weight loss programmes in the UK in obese adults: body
composition changes over 6 months.
Asia Pac J Clin Nutr. 2004 Aug;13(Suppl):S146.
http://www.slim-fast.com/plan/index.asp?bhcp=1 Accessed
September 16, 2004.
Halford JCG, Ball MF, Pontin EE, Maharjan LB, Dovey TM, Pinkney
JH, Wilding JPH, Mela DJ. The impact of using meal-replacements
versus standard dietetic advice on body weight, appetite, mood, and
satisfaction during a 12-week weight control. North American
Association for the Study of Obesity Conference, November 14-18,
2004, Las Vegas, Nevada.
2012 72
73. Pennington Biomedical Research
Center
Division of Education
Heli J. Roy, PhD, RD
Beth Kalicki
Division of Education
Phillip Brantley, PhD, Director
Pennington Biomedical Research Center
Steven Heymsfield, MD, Executive Director
2012 73
74. About Our Company…
The Pennington Biomedical Research Center is a world-renowned nutrition research center.
Mission:
To promote healthier lives through research and education in nutrition and preventive medicine.
The Pennington Center has several research areas, including:
Clinical Obesity Research
Experimental Obesity
Functional Foods
Health and Performance Enhancement
Nutrition and Chronic Diseases
Nutrition and the Brain
Dementia, Alzheimer’s and healthy aging
Diet, exercise, weight loss and weight loss maintenance
The research fostered in these areas can have a profound impact on healthy living and on the prevention of common
chronic diseases, such as heart disease, cancer, diabetes, hypertension and osteoporosis.
The Division of Education provides education and information to the scientific community and the public about
research findings, training programs and research areas, and coordinates educational events for the public on various
health issues.
We invite people of all ages and backgrounds to participate in the exciting research studies being conducted at the
Pennington Center in Baton Rouge, Louisiana. If you would like to take part, visit the clinical trials web page at
www.pbrc.edu or call (225) 763-3000.
2012 74