What is obesity?
How common is obesity?
What are the comorbidities associated with obesity?
How do I assess obesity in my clinical practice?
What are the treatment options? What are reasonable expectations for weight loss?
What’s the first step in a weight loss program?
How do I decide if a particular diet is effective or safe for my patients?
Do commercial weight loss programs work?
What types of and how much exercise should be recommended for weight control?
What are the medications currently available for weight control?
Are over-the-counter medications, dietary supplements, or herbal preparations effective? Are they safe?
What are the surgical options for obesity? Who is a candidate?
I have heard that a cycle of losing and regaining weight may be harmful. Is this true?
What treatment options are usually covered or not covered by health insurance?
Is reducing dietary fat enough? What about cholesterol?
Is treatment of obesity in children and adolescents different from that of adults?
Q: What is obesity and how is it defined?
A: Obesity is a complex problem: its etiology is derived from the patient’s diet, their genetics, and environmental factors such as a sedentary lifestyle and exercise. Other times obesity is secondary to a chronic disease such as diabetes, or hypothyroidism.
Genes provide the disposition for obesity and thus have a permissive role in promoting obesity, but are not sufficient without the right environmental factors. There are no single-gene models for obesity that can account for the dramatic rise in obesity prevalence. However, such single-gene defects do exist in humans but there are approximately 10 persons that have been identified worldwide.
Environmental factors thought to be important to obesity include both diet and level of physical activity. Dietary factors proposed to contribute to obesity include overall increases in calorie intake, larger portions, increases in the number of meals eaten out of the home, more frequent snacking, and a high fat diet. Low levels of physical activity reflect time spent on exercise, but also markedly diminished levels of energy spent on day-to-day activities during work and recreation.
What does the National Institute of Diabetic, Digestive, and Kidney disease say…
What does the National Heart, Lung and Blood Institute say…
Q: How common is obesity?
A: Over 60% of U.S. adults are considered to be overweight or obese. The prevalence has been increasing and is expected to continue to rise. Since obesity is associated with multiple comorbidities as well as diminished quality of life, identifying overweight and obesity is important. Health care providers can provide critical information about risks of obesity, and can help patients choose reasonable and appropriate treatments. Obesity is also increasing in pediatric populations.
What does the Center for Disease Control say…
Q: What are the comorbidities associated with obesity? Are there any particular comorbidities that need particular attention?
A: Obesity increases risk for certain problems. Thus it is possible to be obese and free of comorbidities. However, the link between obesity and some comorbidities, such as type 2 diabetes and obstructive sleep apnea, is so powerful that the majority of patients with these conditions will be obese. Many times obese patients have difficulty obtaining treatment for theses conditions. Additionally, there are social and psychological effects of obesity such as prejudice, unemployment, verbal harassment, low self-esteem and depression.
Risk for most comorbidities increases with BMI (a marker for degree of overweight). This is the rationale for consideration of treatment options which themselves may have associated risks (such as medications or surgery) at higher levels of BMI.
What does the U.S. Surgeon General say …
What does the National Heart, Lung and Blood Institute say…
Q: How do I assess obesity in my clinical practice?
A: The current method for classifying body weight is by use of the body mass index. The body mass index, or BMI, is expressed as weight (kg)/ height (m)2. Use of the body mass index allows comparison of individuals across a range of heights. BMI correlates well with body fat, and correlates highly with health risk. Thus, high levels of BMI are associated with excess high levels of body fat and obesity-related comorbidities. How BMI is used to classify weight and several helpful tables or calculators are available in the links provided. It is also critical to take a through history the patient’s eating habits, weight loss habits, nutrition history, family history, social history and activity level.
What does the National Heart, Lung and Blood Institute say…
What does the National Heart, Lung and Blood Institute say… (Aim for a Healthy Weight - Patients and Public)
What does the National Heart, Lung and Blood Institute say… (Determination of Degree of Abdominal Obesity)
What does the National Heart, Lung and Blood Institute say… (BMI Calculator)
Q: What are the treatment options? What are reasonable expectations for weight loss?
A: Every patient will respond to a weight loss program individually. It is important to match the person to the right program. It is well studied that a 10 % weight loss over 3 to 6 months is a reasonable starting point. A successful weight loss program combines diet modification and exercise. It is important to stress to you patient that there is no quick fix.
All weight control strategies ultimately need to alter the balance between energy intake and energy expenditure: Body Weight = Energy Intake - Energy Expenditure.
Both reductions in intake and increases in expenditure have roles in weight control. However, to create a caloric deficit, it is usually more effective to reduce intake. For example, consumption of 100 kcal can be accomplished in several bites, whereas expending 100 kcal requires walking about one mile.
Diet and exercise are behaviors, and long-term changes in behavior require considerable effort. “Behavior modification” is not a separate treatment option for obesity, but a method for promoting changes in behaviors that ultimately influence body weight.
Weight loss medications and surgery are adjuncts that improve a patient’s ability to create a deficit in energy intake. Adjuncts improve response rates to lifestyle interventions, but are far less effective when not paired with appropriate diet and physical activity programs.
What does the National Heart, Lung and Blood Institute say…
What does the National Institute of Diabetic, Digestive, and Kidney Disease say…
Q: What’s the first step in a weight loss program?
A: Changing eating and activity patterns in a meaningful way means recognizing what current behaviors are, and understanding why they occur. Self-monitoring is a key first-step in making important changes. It is often useful to keep a diary of what is eaten, how much, the time it takes to eat, the situation in which food is consumed, and the antecedents and sequelae of eating. This will help to determine the contributions of the many factors that contribute to eating, such as hunger, palatability, emotions such as stress, boredom or loneliness, the pattern and frequency of eating, and location of eating.
Q: How do I decide if a particular diet is effective or safe for my patients?
A: Weight loss diets can be categorized in several ways, such as by the level of caloric intake or by the composition of the diet.
Low calorie diets (LCDs) usually represent a reduction in intake of 500-1000 kcal/day from the weight-maintenance level of intake. While these diets are defined as reductions to an intake level of 800 kcal/day, this degree of restriction is seldom necessary for weight loss. Low calorie diets typically result in a loss of 1-2 lb/week. An advantage of this type of diet is that is modifiable for long-term use.
Caloric reductions on LCDs can be achieved by reductions in portions sizes, changes in the frequency of eating or snacking, of by changing the macronutrient composition (carbohydrate, protein, and fat) of the diet.
Very low calorie diets (VLCDs) represent intake of less than 800 kcal/day. These diets can be composed of common food items, but are more frequently consumed as liquid products and bars specifically designed for VLCDs. Weight loss is more rapid (about 2-4 pounds/week), but regular medical supervision is needed. Rapid weight loss on a VLCD is no better maintained than with an LCD.
Popular or fad diets often entail restriction of specific macronutrients, food groups, or consumption of food in specific patterns. The efficacy and safety of fad diets has not been scientifically demonstrated. Proponents of fad diets cite the poor long-term performance of “traditional” weight loss diets and continued increase in obesity prevalence as rationale for advocating new methods. However, several fad diets may increase heath risks, and until information regarding efficacy and safety is known, their use is not recommended.
What does the National Heart, Lung and Blood Institute say…
What does the National Heart, Lung and Blood Institute say about healthy dining out …
What does the National Heart, Lung and Blood Institute say about dietary therapies ...
Q: Do commercial weight loss programs work?
A: Commercial programs vary widely in the diet recommendations, whether food is to be provided by the client or purchased as part of the program, and how often a client attends. Some programs are based on exchange systems where there can be a variety of food choices, while others can be quite restrictive. And the cost varies widely too. Some programs offer guidance about physical activity, some offer behavioral counseling, and some have a spiritual component. Some programs also recommend their own brand or other brand of dietary supplements.
All programs, however, are based on the need to decrease intake. Another important component of commercial programs is that regular attendance encourages regular attention to lifestyle changes. Programs often offer great flexibility in when and how often clients can “check in”. And programs often have multiple community locations, which facilitates attendance.
Many programs have websites, offer literature, or will welcome a fact-finding visit. Programs that don’t provide detail about their plan should be approached with some caution. Also, you can ask about a program’s record of weight loss and maintenance of lost weight. Most programs, however, will not be able to provide you with information about their success.
What does the National Institute of Diabetic, Digestive, and Kidney disease say…
Q: What types of and how much exercise should be recommended for weight control?
A: There are multiple reasons to include exercise in a weight-control plan. Activity, even though less effective than restricting intake in creating a caloric deficit, does contribute to that deficit. Activity may have a very important role in maintaining lost weight. In studies of successful maintainers of lost weight, one of the most important factors associated with long-term weight control is regular physical activity. Also, increasing physical activity at any level of body weight results in health benefits, even if weight is not lost. Finally, increasing activity improves mood and sense of well-being.
What does the National Institute of Diabetic, Digestive, and Kidney disease say… (Active at Any Size)
What does the National Institute of Diabetic, Digestive, and Kidney disease say… (Physical Activity and Weight Control)
What does the National Heart, Lung and Blood Institute say…
Q: What are the medications currently available for weight control?
Prescription medications work by suppressing intake of food or by decreasing the absorption of food that is eaten. The choice of medication depends on eating patterns, current medications and health conditions, and patient preference. It is important to remember that medications are adjuncts and work best when used in conjunction with other lifestyle interventions. Use of medications in weight loss should not alter the initial goal of weight loss of approximately 10% of body weight.
What does the National Heart, Lung and Blood Institute say…
What does the National Institute of Diabetic, Digestive, and Kidney disease say… (Prescription Medications for the Treatment of Obesity)
Q: Are over-the-counter medications, dietary supplements, or herbal preparations effective? Are they safe?
A: Most over-the-counter (OTC) medications, dietary supplements, and herbal preparations for weight loss have not been extensively tested and thus effectiveness or safety is not known. The most common OTC medication, phenylpropanolamine, was removed from the market recently, but this medication was less effective than current prescription medications for weight loss.
Herbal preparations containing ephedra, or ma huang, have been associated with serious side effects such as myocardial infarction (heart attack), stroke, and death. While the active ingredient in ephedra may be an effective weight loss aid, the current preparations containing ephedra are not regulated as drugs. Thus use of ephedra is not recommended at this time.
Q: What are the surgical options for obesity? Who is a candidate?
Surgery is an option for those who have a BMI over 40 kg/m2, or a BMI over 35 kg/m2 and serious comorbidities such as diabetes, hypertension, or sleep apnea, and should be considered in patients who have not been able to achieve a healthy weight by non-surgical means. Current surgical options always involve a degree of gastric restriction to help reduce intake. Some options also involve varying degrees of malabsorption. While surgery is a powerful tool that can markedly increase a patient’s ability to achieve and maintain a healthier weight, it is important to recognize that efficacy also requires considerable patient effort and life-long vigilance to diet and exercise. Thus, only patients who are well motivated and understand the implications of the surgical procedure should be considered.
What does the National Heart, Lung and Blood Institute say…
Q: I have heard that a cycle of losing and regaining weight may be harmful. Is this true?
A: The process of losing and regaining weight repetitively, termed weight cycling, is a topic of debate among obesity experts. There is not consistent evidence that weight-cycling influences risk for cardiovascular or other comorbidities, or that it makes subsequent weight loss more difficult. Weight cyclers may experience frustration over the pattern of loss and regain, but there is little evidence that weight cycling contributes to depression or eating disorders. For these reasons, many obesity experts recommend that efforts to lose weight be made even if there is a history of weight cycling.
It is important to set reasonable initial goals for weight loss and to emphasize that maintenance of lost weight is a lifelong process that requires significant effort. Rapid loss without effort to change longer-term lifestyle patterns may promote regain after loss, and thus promote weight cycling.
Q: What treatment options are usually covered or not covered by health insurance?
A: Coverage for obesity treatment varies widely among health insurance plans. Some plans cover little or no treatment for obesity, while others cover a range of treatment options. Most policies are clear about what is covered - review of the policy or contacting the insurer will provide answers. Many plans will provide coverage of outpatient visits and laboratory tests that are part of medically-supervised programs.
Food and meal-replacements are generally not covered by insurers. Some plans may cover part or all of the costs of commercial programs.
Medications for weight loss are covered by some plans. This often requires special pre-approval that must be submitted by a physician.
Surgery for obesity is often covered, although not all types of procedures may be included. If you are considering surgery, review your policy or contact your health insurer.
Q: Is reducing dietary fat enough? What about cholesterol?
A: Reducing dietary fat without reducing calories has been shown to result in a small average loss (less than 10 pounds), so reducing fat with additional attention to other factors may be needed.
Reducing fat (especially saturated fat) and cholesterol in the diet may help lower blood cholesterol. However, reducing body weight is likely to be equally or more effective in lowering blood cholesterol than reductions in dietary fat or cholesterol.
Q: Is treatment of obesity in children and adolescents different from that of adults?
A: Obesity prevalence in children is increasing at an alarming rate. Treatment of children and adolescents differs from the approach in adults in several ways. The goal of treatment in children may sometimes be to keep weight stable and allow the child to “grow into” their weight. Most childhood obesity experts believe that families should have an active role in treatment of children. Drug treatment of childhood obesity is only conducted under research protocols at this time. Surgery is rarely an option for children or adolescents unless it is deemed to be life saving.
What does the CDC say…
What does the National Institute of Diabetic, Digestive, and Kidney disease say…
What does the Surgeon General say…
