Taking back control

Obesity should be screened for at every health examination.17 Unfortunately, the Mayo Clinic found that only 20% of obese patients had a diagnosis or an obesity-management plan documented in their medical record. Multiple variables come into play when calculating overall medical risks for obesity. BMI is calculated from height and weight measurements. Weight at age 18 years and weight gain since that time are important data, as are number of attempts at and degree of success in weight-loss efforts and weight maintenance. Such diagnostic measurements as BP, lipid profiles, and fasting glucose provide valuable insight into the health of the obese individual. Evaluation of lifestyle habits (e.g., tobacco use, exercise regimens, dietary patterns, and current medications) and pathologic disorders (including hypothyroidism, OSA, diabetes mellitus, and psychological disorders) are essential when developing a weight-loss program with a patient. While many clinicians and patients like to believe that obesity results from a medical or genetic malfunction, the culprit is most often an imbalance between calories expended vs. calories consumed.

As with most illnesses and disease, recognition of the problem is only the first step. Throughout the literature, a three-tiered approach is recommended.18,19 This approach includes dietary modification, regular exercise, and behavioral exploration. Diet and exercise provide the necessary adjustment to reverse the balance of energy intake and expenditure. Behavioral exploration helps identify and correct underlying psychosocial dysfunctions contributing to overeating and/or lack of activity. Unfortunately, patients undergoing weight-reduction strategies experience a 95% failure rate within five to seven years.20 Health-care providers must anticipate weight regain after a weight-loss strategy is halted.21 Healthful dietary intake and a consistent and regular exercise program are essential to long-term success.

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Prescribing an optimal dietary strategy requires in-depth evaluation of the person’s eating habits and preferences and may be best suited to a nutritionist. No single dietary strategy produces consistent success over the others.20,22 High-protein, low-fat diets promote early and prolonged satiety; however, this type of diet is difficult to adhere to on a long-term basis (especially for those who do not like meat). High-carbohydrate, low-fat diets require more frequent consumption and smaller portions, which can be a challenge. Calorie-controlled diets can be difficult to adhere to and monitor, but participation in the meetings and support groups associated with these plans improves the chances of success.

When creating a dietary strategy for patients, include their favorite healthy foods, simplify meal planning, emphasize the necessary long-term commitment to changing dietary patterns, and encourage anticipation of upcoming temptations such as holidays and special celebrations. For reasons that remain unclear, diminished weight loss and success occurs after approximately the first six months. Those seeking to lose a large amount of weight will need reinforcement of personal goals and support.

Developing an exercise plan that makes regular participation appealing presents additional challenges. The CDC provides exercise guidelines for both weight maintenance and weight loss.23 For weight maintenance, regular exercise should account for 150 minutes per week of moderately intense activities in at least 10-minute increments, and muscle-strengthening activities should be performed using all muscle groups at least twice weekly. For weight loss, the moderate-intensity exercise should be done for 300 minutes a week in addition to the muscle-strengthening activities.

Exercise has a positive effect on weight loss and overall health, especially when combined with a healthful diet.24 Moderate-intensity activities increase heart and respiratory rates and sweating. These activities include brisk walks, bike-riding on level ground, and water aerobics. Vigorous exercise has been found to be more effective than moderate exercise. Vigorous-intensity activities include jogging, bike riding on hills, swimming laps, and playing fast-paced basketball. A pedometer-based walking regimen with a goal of at least 10,000 steps per day is an effective and easily developed program.25 Choosing a variety of activities promotes long-term compliance. Gradual transition into the moderate- and vigorous-intensity levels and lengthening of each exercise period allows the cardiovascular, pulmonary, and musculoskeletal systems to adapt.

Regular exercise also reduces the risk or improves control of such serious comorbidities as cardiovascular disease, diabetes mellitus, cancer, metabolic syndrome, muscle atrophy, joint stiffness, and mental-health disorders. For those individuals struggling with health issues that hinder participation in exercise, suggest recumbent stationary bikes or water aerobics. Referral to a physical therapist with bariatric experience adds other options to a comprehensive weight-loss plan.

Behavioral and cognitive therapy was developed in the 1960s as an adjunct to weight-loss programs with a focus on identifying eating patterns and disorders. It is most effective when combined with a comprehensive diet-and-exercise program. Components include support groups, patient-self-monitoring through food and exercise diaries, stimulus control through recognition of emotional or habitual triggers, goal-setting, cognitive restructuring, development of social support networks, and learning effective problem-solving skills.26

Assess overweight and obese patients for such other unhealthy behaviors as tobacco use, excessive alcohol use, uncontrolled stress with poor coping mechanisms, poor sleep patterns, imbalances between work and relaxation, and avoidance of routine health-care examinations.

Pharmacologic interventions

The second tier of a weight-loss program involves introduction of prescription and OTC pharmacologic aides after at least six months of diet and exercise. Numerous OTC diet pills are available, including herbal remedies and appetite suppressants. There are few evidence-based alternatives available to the health-care provider, and an in-depth review of all the nonprescription diet aids is beyond the scope of this paper.

Phentermine is an anorexiant and sympathomimetic that was previously combined with fenfluramine until it was shown to cause disastrous cardiac illness. As a stand-alone agent, phentermine is an effective short-term diet pill. It is a schedule IV drug closely related to amphetamines. Dosages range from 18.75 mg to 37.5 mg daily. A similar product, sibutramine (Meridia), was voluntarily withdrawn from the U.S. market because of emerging evidence indicating increased risks for cardiovascular adverse events, including MI and stroke. The lipase inhibitor orlistat is available in both prescription (Xenical) and OTC (Alli) strengths. Orlistat inhibits the binding of dietary fat by acting as a malabsorptive agent in the digestive tract. The most common side effect, diarrhea, is proportional to the intake of high-fat foods. Dosages range from 60 mg to 120 mg t.i.d. before meals.

Human chorionic gonadotropin (hCG) hormone recently returned to the market. Its off-label use for weight loss is controversial. HCG was initially introduced in 1954 for use in conjunction with a very-low-calorie diet (500-800 kcal/day). In the early 1960s, JAMA warned against this diet, stating it was potentially more hazardous to patients than was obesity.27 Research published later indicated that hCG was no more effective than placebo.28 The following decade, the FDA required producers of hCG to label the drug with a warning against use for weight loss or fat redistribution; hCG is not approved for use as a weight-loss medication.27 In 1976, results of a double-blind study attempting to validate the claims of the hCG diet found that hCG injections did not enhance the results of a very-low-calorie diet program.29 The benefit of the hCG diet program is not derived so much from the hormone as from the very-low-calorie diet prescribed concurrently.

Bariatric surgery

Bariatric surgery should be considered only for those persons for whom all other avenues have failed. Bariatric surgery provides a tool to assist with weight-loss efforts and requires ongoing healthy dietary consumption and exercise for life; otherwise, failure is inevitable. In 1991, the National Institutes of Health Consensus Conference identified qualifying criteria for weight-loss surgery. A patient must demonstrate a BMI >40 or a BMI >35 associated with at least one comorbidity due to excess body weight (e.g., hypertension, diabetes mellitus, OSA).30 The three types of bariatric surgery are malabsorptive (developed more than 40 years ago), restrictive, or a combination.

The most common bariatric surgery is the Roux-en-Y gastric bypass, which is a combination of both malabsorptive and restrictive properties. The process involves creating a small pouch from the upper stomach and attaching it to a short intestinal Roux limb; the remnant stomach and duodenum are reattached lower on the small intestine, creating a Y-connection. The smaller pouch hinders consumption of large quantities of food at one time by causing discomfort or nausea, thereby limiting caloric intake by the patient, who consumes only three meals daily.

Initially performed as an open procedure, Roux-en-Y gastric bypass was fraught with postoperative complications that decreased when it was successfully converted to a laparoscopic procedure. Postoperative complications include anastomotic leak, anastomotic ulceration, stomal stenosis, bowel obstruction, wound infection, GI bleeding, ventral and/or incisional hernias, pneumonia, and pulmonary embolism. In the early post-operative period, fluid and electrolyte imbalances require more diligent structure in intake and monitoring. Nutritional complications continue to provide a challenge to patients in the long term. Because of the bypass component, the pouch is unable to sufficiently absorb protein, iron, or vitamins. Patients are encouraged to follow a diet high in protein (70-100 g daily) to maintain adequate levels. Ferrous fumarate is the iron format best absorbed in the modified GI tract and is recommended for patients after bypass surgery. Vitamin B12 is also poorly absorbed and requires supplementation via subcutaneous, sublingual, or oral route. Due to poor absorption, multivitamin dosing recommendations significantly exceed the minimum daily requirements.