Combination Approaches to Weight Management

We all know that the most effective weight management interventions use a combination of behavior-change strategies related to diet, exercise, and environmental control. Treatment of overweight and obese people must be tailored to the individual’s needs, ability to make changes, and readiness to commit to lifestyle changes. James W. Anderson, MD, Director, Metabolic Research Group, University of Kentucky, recently prepared a great overview of 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

Introduction

The prevalence of overweight and obesity is increasing at an alarming rate in the United States and in most other countries.[1,2] Almost two thirds of US adults are overweight, [1] and the prevalence of extreme or morbid obesity has almost tripled in the last 10 years.[3] The percentage of overweight adolescents in the United States has increased 3-fold in the past 30 years.[4] Unfortunately, many obese individuals have difficulty losing weight, and most have even greater difficulty maintaining weight loss in the long term.[5,6] However, approaches that combine low-energy diets and behavioral management have been shown in studies conducted over the past 5 years to significantly improve weight loss and maintenance.[7]

The most effective interventions use a combination of behavior-change strategies related to diet, exercise, and environmental control. Treatment of overweight and obese people must be tailored to the individual’s needs, ability to make changes, and readiness to commit to lifestyle changes. This review will provide suggestions for approaching overweight or obese patients using interventions that are currently proving effective for persons with a wide range of weight and risk-factor problems.

Approaches to Weight Management

The commonly used approaches that are recommended by primary care providers for weight management are listed in Table 1. Sometimes popular diets, such as low-carbohydrate diets, are endorsed as self-help or physician-counseling recommendations; these are reviewed elsewhere and not discussed further here.[8] However, we do recommend that healthcare providers encourage healthy food choices and practices when patients seek advice. These healthy practices include daily consumption of at least 5 servings of fruits or vegetables and 3 servings of whole grains.[9] On the basis of available data, [7,10] weight loss over a period of 6 months can be classified as modestly effective if weight loss of 2-8 kg (~2.5% to 8% of initial body weight) is achieved; moderately effective if there is weight loss of 9-14 kg (9% to 15%); and highly effective if there is weight loss of > 15 kg (15%).

Meal replacements (MR) have emerged as one of the most cost-effective tools for empowering overweight and obese individuals to lose significant amounts of weight and maintain this weight loss over the long term.[10-14] MR are widely available, inexpensive, and moderately effective.

Physician or primary care provider counseling can be modestly effective, although there are only limited data available on weight-loss outcomes. Subjects receiving placebo in clinical trials of pharmaceutical agents for obesity lose an average of 2.8 kg over the course of 6 months with limited counseling and regularly scheduled office visits.[15] This 2.8 kg may serve as an estimate of the effectiveness of dietitian or physician counseling. A study from the University of California, Los Angeles, of a physician-directed counseling intervention with nutritionist support demonstrated weight loss at 6 months of 8.6 kg ± 1.8 kg in women and 7.0 kg ± 3.7 kg in men. These results probably overestimate the effectiveness of physician counseling, because this was a fairly well-structured study using MR.[16] Nevertheless, an empathetic care provider can encourage, educate, and empower certain individuals to lose substantial amounts of weight.

Table 1. Lifestyle Approaches to Management of Overweight and Obesity

Description	Components	Weight Loss at 6 Months (kg)	Example	References
Self-help	Encouraged to lose weight	1.7		17
Meal replacements	Use 2 MR* daily	9.1	Slim-Fast	10-13
Physician counseling	Mutual goal setting; physical activity goals; plan to reduce energy intake; may include MR use	3.0 to 9.0		15,16
Community program	Education program; weekly group sessions; calorie-counting system; packaged food available	6.1	Weight Watchers	17
Dietetic counseling	Tailored to individual	4.1		16
Pharmacotherapy	Use of approved agent.	4 to 6	Sibutramine or orlistat	15
Behavioral program	Behavioral program; weekly group meetings; exercise expected; record keeping.	11.4		10
Low-energy diet program	Behavioral program; weekly group meetings; weekly phone calls; MR use required (entrees, vegetables and fruits optional); exercise expected; calorie-counting system; record keeping.	20.1	Health Management Resources	10
Very-low-energy diet	All components of low-energy diet program except use of vegetables and fruits	21.3	Health Management Resources	10

Community programs, such as Weight Watchers, can be modestly effective for some individuals.[17] The accountability of weekly weigh-ins, the group dynamics, and the specific guidance in food selection contribute to success.

Dietetic counseling also appears to be modestly effective,[16] but the out-of-pocket expense is a deterrent for many individuals.

Pharmacotherapy, on average, is only modestly effective[15] and is fairly expensive. Pharmacotherapy combined with a strong lifestyle intervention program including use of MR, pedometers, and lifestyle diaries can be moderately effective.[18]

Behavioral programs can be moderately effective for weight loss.[10] Most of these programs use low-energy diets without MR or medical supervision. These programs tend to be located in academic centers with obesity research programs and are not widely available.[19, 20]

Low-energy diets (LED) and very-low-energy diets (VLED) using MR and behavior management are highly effective; most of the patients who participate in these programs require medical supervision. VLED became widely used about 25 years ago. These were highly effective, with weight loss averaging > 20% of initial body weight. Most of these weight management programs had weekly behavior education classes and utilized shakes that met protein requirements from high-quality protein sources (milk or soy).[10, 21] As the behavior education intervention improved, entrees and bars were incorporated into the regimen. With improved behavioral education, research studies indicated that LED were as effective as VLED in improving weight loss.[7]

Next time we will overview the methods for Tailoring Therapy for Overweight or Obese Patients

References
1. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA. 2002;288:1723-1727.
2. James PT, Leach R, Kalamara E, Shayeghi M. The worldwide obesity epidemic. Obes Res. 2001;9:228S-233S.
3. Freedman DS, Khan LK, Serdula MK, Galuska DA, Dietz WH. Trends and correlates of class 3 obesity in the United States from 1990 through 2000. JAMA. 2002;288:1758-1761.
4. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA. 2002;288:1728-1732.
5. Anderson JW, Vichitbandra S, Qian W, Krysico RJ. Long-term weight maintenance after an intensive weight-loss program. J Am Coll Nutr. 1999;18:620-627.
6. Anderson JW, Konz EC, Frederich RC, Wood CL. Long-term weight-loss maintenance: a meta-analysis of US studies. Am J Clin Nutr. 2001;74:579-584.
7. Anderson JW, Konz EC. Very-low calorie diet and meal replacement use for weight management. In: Mela D, ed. Food, Diet and Obesity. Cambridge, UK: Woodhead Publishing; 2004. In press.
8. Anderson JW, Konz EC, Jenkins DJA. Health advantages and disadvantages of weight-reducing diets: a computer analysis and critical review. J Am Coll Nutr. 2000;19:578-590.
9. Anderson JW, Hanna TJ, Peng X, Kryscio RJ. Whole grain foods and heart disease risk. J Am Coll Nutr. 2000;19:291S-299S.
10. Anderson JW, Luan J, Hoie LH. Structured weight-loss programs: A meta-analysis of weight loss at 24 weeks and assessment of effects of intensity of intervention. Adv Ther. 2004;21:61-75.
11. Heymsfield SB, van Mierlo C, van der Knaap HCM, Heo M, Frier HI. Weight management using a meal replacement strategy: meta and pooling analysis from six studies. Int J Obesity. 2003;27:537-549.
12. Rothacker DQ. Five-year self-management of weight using meal replacements: comparison with matched controls in rural Wisconsin. Nutrition. 2000;16:348.
13. Blackburn GL, Rothacker D. Ten-year self-management of weight using a meal replacement diet plan: comparison with matched controls [abstract]. Obes Res. 2003;11:A103.
14. Flechtner-Mors M, Ditschuneit HH, Johnson TD, Suchard MA. Metabolic and weight loss effects of long-term dietary intervention in obese patients: four-year results. Obes Res. 2000;8:399-402.
15. Haddock CK. Pharmacotherapy for obesity: a quantitative analysis of four decades of published randomized clinical trials. Int J Obesity. 2003;26:262-273.
16. Bowerman S, Bellman M, Saltsman P et al. Implementation of a primary care physician network obesity management program. Obes Res. 2001;9:321S-325S.
17. Heshka S, Anderson JW, Atkinson RL et al. Weight loss with self-help compared with a structured commercial program: a randomized trial. JAMA. 2003;289:1799-1805.
18. Anderson JW, Greenway FL, Fujioka K, Gadde KM, McKinney J, O’Neil PM. Bupropion SR significantly enhances weight loss: a 24-week double-blind, placebo-controlled trial with placebo group randomized to bupropion SR during 24-week extension. Obes Res. 2002;10:633-641.
19. Wadden TA, Sarwer DB, Berkowitz RI. Behavioural treatment of the overweight patient. Bailliere Clin Endoc. 1999;13:93-107.
20. Wing RR, Anglin K. Effectiveness of a behavioral weight control program for blacks and whites with NIDDM. Diabetes Care. 1996;19:409-413.
21. Anderson JW, Hamilton CC, Brinkman-Kaplan VL. Benefits and risks of an intensive very-low-calorie diet program for severe obesity. Am J Gastroenterol. 1992;87:6-15.