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Combination Approaches to Weight Management Part 2

Tailoring Therapy for Overweight or Obese Patients- is a continuation of Dr. James W. Anderson’s, recently prepared overview of Combination Approaches to Weight Management. This week he helps us design a workable program for Overweight or Obese Patients

Combination Approaches to Weight Management

James W. Anderson, MD, Director, Metabolic Research Group; Professor of Medicine and Clinical Nutrition, University of Kentucky; Director, HMR Weight Management Program, University of Kentucky; President, Obesity Research Network, Lexington, Kentucky

Part 2 of 3

Tailoring Therapy for Overweight or Obese Patients

Patients should be weighed at each office visit, and accurate height measurements should be available. At regular intervals, the body mass index (BMI) should be calculated and patients should be counseled about desirable weights. At all adult ages, desirable BMI values are 22 kg/m2 for women and 23 kg/m2 for men.[22] For persons who are not trained athletes, differences in muscle mass can be ignored. For persons with large frames (the middle finger does not overlap the thumb when the right hand is placed around their left wrist), one can add 10% to their desirable weight and adjust the BMI values that signify overweight and obesity for these individuals. Persons whose BMI is > 25 kg/m2 should be advised that they are overweight, and persons whose BMI is > 30 kg/m2 should be advised that they are obese. In general, everyone should be counseled about the desirability of a nonobese weight. If the BMI is > 40 kg/m,2 a nonobese target weight is sometimes set as a weight goal.

Guidelines for management of overweight or obese individuals are summarized in Table 2. Because the natural history is for overweight individuals to gain further weight, persons with BMI values of 25-30 kg/m2 should be counseled to achieve and maintain a desirable body weight even if they have no risk factors. Overweight or obese women who have gained weight after 18 years of age have a 6-fold higher risk for coronary heart disease than do non-overweight women who have not gained weight after age 18.[23] Weight gain and obesity can increase the risk for developing diabetes to 90-fold greater than the risk for nonobese persons who have not gained weight since adolescence.[22] Risk factors that should prompt the encouragement to lose weight include family history of premature atherosclerotic cardiovascular disease, dyslipidemia, hypertension, cigarette smoking, obstructive sleep apnea, excessive dyspnea with exertion, musculoskeletal problems or degenerative joint disease, varicose vein disease, and gastroesophageal reflux disease.

Table 2. Guidelines for Management of Overweight or Obese Individuals*


Weight/Risk Assessment

Preferred Treatment

More Intense Treatment

Less Intense Treatment

BMI 25-30 kg/m2
without risk factors

Meal replacements

Physician counseling

Self-help

BMI 25-30 kg/m2
with risk factors

Physician counseling

Community program

Meal replacements

BMI 30-35 kg/m2

LED behavioral program

LED behavioral program

Dietetic counseling

BMI 35-40 kg/m2

LED behavioral program

LED behavioral program

Dietetic counseling

BMI 40-50 kg/m2

LED behavioral program

Bariatric surgery

Not recommended

BMI > 50 kg/m2

Bariatric surgery

Bariatric surgery

LED behavioral program

*Modified from Anderson and Wadden.[31] Behavioral programs are not included because effective programs are not widely available.[10]
Pharmacotherapy can be used for all groups except the top group with no risk factors.
LED – low-energy diet (800-1200 kcal/day)

Overweight adolescents and adults should be educated about their current weight status and nonobese weight targets. Often this information and simple guidance about reductions in intake of high-sugar drinks and high-fat foods and snacks will enable an overweight individual to achieve and maintain a nonobese weight. Instructing patients to use 2 MR daily, either in place of a meal or as snacks, is an extremely cost-effective way for healthcare providers to encourage weight loss. MR can be used for breakfast with or without fruit and for other meals with or without vegetables or fruits. Referral to a community program is moderately effective for some overweight or obese individuals. Most patients need the accountability of regular office visits with their primary care provider to sustain these lifestyle changes. Having a dietitian available in the office enhances the effectiveness of nutrition counseling. Referral to a consulting dietitian is recommended, but often patients do not follow through with the visit because of the expense and inconvenience.

The most effective weight-loss programs use LED or VLED, weekly behavioral classes, and record keeping. At the University of Kentucky, Lexington, our Health Management Resources (HMR) Program, for example, has 4 distinct options: a medically supervised option for persons with BMI > 35 kg/m2 or other risk factors that require medical monitoring; an intermediate option for persons with BMI values of 30-35 kg/m2; a moderate option without medical monitoring for persons with BMI < 30 kg/m2; and a Healthy Solutions option without medical monitoring. The first 3 programs use LED with 800-1000 kcal/day and provide nutrition through 5 MR shakes daily or 3 shakes and 2 MR entrees daily. The Healthy Solutions option provides 1200-1400 kcal/day with 3 shakes, 2 entrees, and 5 servings of fruits or vegetables. Current weight loss with these programs averages as follows: medically supervised, 20.1% of initial weight in 24 weeks; intermediate, 17.8% in 21 weeks; moderate, 15.5% in 18 weeks; and Healthy Solutions, 15.4% in 20 weeks.[24]

Currently we no longer use VLED in our HMR Program, but we prescribe LED providing 800-1000 kcal/day. The higher energy intake is better tolerated by patients, and we see substantially fewer side effects. However, weight loss averages are very similar with current LED compared with previous VLED, and a much higher percentage of morbidly obese persons achieve weight loss of > 100 pounds.[25] Some patients have lost 100 pounds in the Healthy Solutions option, and some have completed their loss of > 100 pounds in the maintenance phase of the program. We encourage all participants to enter the maintenance phase of our program for at least 6 months after completing the weight-loss phase. Recent follow-up information indicates that persons who lose > 100 pounds are keeping off 70% of their weight loss for an average of > 3 years.[25]

Morbidly obese patients should, in our assessment, enroll in an intensive behavioral LED program before being referred for bariatric surgery. Currently we have > 90 patients in our HMR Program at the University of Kentucky who have lost > 100 pounds.[26] This is clearly safer and better tolerated by patients than bariatric surgery. For obese individuals who are unable to achieve and maintain an acceptable body weight, gastric bypass surgery by the minimally invasive route is the treatment of choice.[27]

Next time we will Integrate Lifestyle Components

To read part one of this series please click here.

References

  1. Anderson JW, Kendall CWC, Jenkins DJA. Importance of weight management in type 2 diabetes: review with meta-analysis of clinical studies. J Am Coll Nutr. 2003;22:331-339.
  2. Anderson JW, Konz EC. Obesity and disease management: Effects of weight loss on co-morbid conditions. Obes Res. 2001;9:326S-334S.
  3. Gotthelf L, Anderson JW, O’Brien B. Weight loss in overweight or obese individuals with different structured interventions in an intense behavioral program [abstract]. Obes Res. 2004;12.
  4. Anderson JW. Improved long-term maintenance of weight loss with ongoing involvement in weight management program. Obes Res. 2004;12:156-P.
  5. Anderson JW. Meal replacement use for patients losing >100 pounds in a behavioral, low-energy diet program. Obes Res. 2004;12:145-P.
  6. Steinbrook R. Surgery for severe obesity. N Engl J Med. 2004;350:1075-1079.