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Chapter 4

Treatment Options

As the rate of obesity increases, so has our appreciation that this condition is complex. The age-old approach to weight loss—calories consumed must be balanced against calories expended—is not incorrect but is far from complete. Genetic susceptibility and environmental encouragement have joined forces to boost consumption and minimize activity, accelerating the incidence and consequences of excess body weight. Several tools, supported by medical research, are available for fighting excess weight. However, tools alone assist but do not solve the problem. Sustainable weight loss still requires that the number of calories out surpasses the number of calories in. To accomplish this, we offer information and support on how to change, teach the basics of meal planning, and invite everyone to move more and sit less. If these patient-driven activities are insufficient, drug therapy and bariatric surgery may be appropriate adjuncts.

WHO (2007) and NHLBI (2010) describe methods that address caloric balance. The stated goal is to reduce energy intake so that it is lower than calories burned during the weight-loss phase and to rebalance caloric intake to match calorie expenditure during the weight-maintenance phase. Successful long-term weight loss has been defined as an intentional 10% weight reduction from baseline that is maintained for one year (Wing 2005). To reduce calories eaten or to increase calories burned requires change.

Lifestyle Change

Behavioral treatment is an essential component of any credible obesity treatment program (Berkel 2005, Foster 2004). Besides addressing the explicit problem behavior, behavioral treatment also addresses the ideas and emotions associated with having and changing behavior (Foster 2005). The primary targets for lifestyle change are eating habits and physical activity levels. However, changing behavior is, by itself, a skill that must be learned. Learning how to change is akin to learning how to learn. Once established, those skills offer the individual the power to keep changing and learning in the future. Successfully making changes is much more likely if people experience support for their efforts as well as guidance. Because obesity is a chronic condition, gaining skill and confidence in how to change behavior is vital to sustained weight loss.

The Core Features of Behavioral Treatment

• Observation. Self-monitor eating habits and physical activity.

• Stimulus control. Identify and limit exposure to cues that prompt overeating.

• Cognitive restructuring. Identify and modify unrealistic goals and inaccurate beliefs about weight regulation.

• Social support. Identify others who can help support your behavior change efforts.

• Problem solving. Address issues related to eating and physical activity.

• Relapse prevention. Engage in maintenance of the achieved weight loss. Reevaluate setbacks and view these as learning experiences rather than failures.

Behavioral treatment can also include stress management (NHLBI 1998) and support for balanced and flexible food choices instead of structured diets as a means to improving nutrition (WHO 2000).

Meal Planning

“Meal planning” replaces the term “diet” and refers to the professionally recommended plan for improving someone’s dietary intake. Such plans are based on portion sizes, nutrient composition, and food distribution intakes that are likely to facilitate weight control. However, the actual meal plan as devised with a patient may only identify specific actions to help move the usual eating pattern toward a recommended one. Examples may be to add an apple to lunch, include a late afternoon snack, and/or switch from soft drinks to tea or water. Many patients benefit from more structure (calculated meal plans, recipes, prepared food) or simplified meals (a week of menus), especially in the beginning. People often have much to learn about how to select and prepare food. The work we do with a patient to devise an eating strategy is called meal planning.

Meal planning is an essential component of all weight-management strategies. A plan that somehow lowers caloric intake is typically necessary for weight loss, but this does not necessarily mean that an individual will always need to consume a smaller amount (volume) of food or actually count calories. Plans can change. The goal, as always, is to devise a meal plan that fits the individual who plans to use it.

Core Considerations for Building Meal Plans

• Space food intake to fuel energy needs and avoid excess hunger

• Limit portion size and frequent snacking

• Choose foods that supply nutrients, which contribute to health by:

+ Eating a variety of foods from all of the food groups

+ Emphasizing high-fiber plant food: whole grains, fruits, vegetables, cooked dried beans, nuts, seeds, etc.

+ Choosing lean protein

+ Minimizing saturated and/or trans fat intake

• Consume adequate non-caloric fluids

Sources: USDA/USDHHS 2010, NHLBI 2005

Physical Activity

According to the 2008 Physical Activity Guidelines for Americans, health improves with at least 150 minutes of aerobic activity and two days of strength training per week. Specifically, guidelines recommend that, for good health, people set as their weekly target 150 minutes (30 minutes for 5 days) of moderate-intensity aerobic activity (i.e., brisk walking) and muscle-strengthening activities on two or more days per week (CDC 2011b). Recommendations suggest that everyone benefits from both aerobic and muscle-strengthening activity. This assumes type, intensity, and duration match individual needs. Appropriate exercise may require professional guidance, especially for those with physical limitations/disability.

Additional exercise is probably required to support weight-loss efforts. Moderate-intensity physical activity for 150–250 minutes per week provides modest weight loss, which can be improved with modest (but not severe) diet restrictions. Physical activity greater than 250 minutes per week is more likely to result in clinically significant weight loss (Donnelly 2009). Although resistance training does not significantly enhance weight loss, it does increase loss of fat mass and improves health risks with or without weight loss. Because muscle burns calories, increasing muscle mass increases calorie needs.

There is evidence that ongoing physical activity helps maintain weight loss (Cooper 2001, Hill 2005). Although the amount required varies greatly from person to person, it is likely that as much as or more (>250 minutes per week) physical activity is required to maintain weight loss (CDC 2011a). Currently, there is no evidence from randomized controlled trials to document physical activity effectiveness to prevent regain (Donnelly 2009).

Although the impact of exercise on weight loss may be modest, both the International Diabetes Federation (IDF 2010) and the CDC (2011a) recommend increased physical activity for weight loss. Exercise as part of a comprehensive weight-loss therapy and weight-maintenance program may decrease body fat and increase lean muscle (U.S. Department of Health and Human Services 2005a,b), as well as offering cardiovascular and other health benefits. Unfortunately, the short-term costs of sacrificing free time, physical comfort, and convenience often seem to outweigh the benefits of a more active lifestyle. Nevertheless, increased physical activity makes successful weight loss more likely.

Many formerly obese people testify that establishing regular routines for physical activity was a turning point in maintaining lifestyle changes. Functional impairment and chronic pain are more prevalent among obese people compared with people in other weight groups (WHO 2000, Larsson 2002, Marcus 2004). Support from health care personnel may be necessary for clients to find ways to be physically active without increasing pain. Facilitating access to safe exercise offers special-needs clients a proven tool for weight-loss maintenance and improved health.

Drug Treatment

For some people, drug therapy for weight loss can be a short-term adjunct to behavior change, meal planning, and activity. Drug treatment may be considered for patients with a BMI ≥30 kg/m2 if treatment with diet, exercise, and behavior change has proven insufficient to reach goals. Drug treatment can also be considered for patients with substantial comorbidities associated with a BMI ≥27 kg/m2 (NIDDK 2007) that have persisted despite improved diet, exercise, and behavior treatment. Although drugs cannot override poor eating habits for sustained weight loss, they can make successful weight loss more attainable and support continued behavior change. Drug therapy can support weight maintenance as well as weight loss.

There have been two types of weight-management drugs. One type targets the gastrointestinal system to inhibit nutrient absorption or cause a feeling of satiety. The other acts on the central nervous system to influence feeding behavior and suppress appetite. For many years there was one available drug for each of these types. The first, orlistat, is now available over-the-counter in a reduced dose and by prescription (FDA 2010a). Late in 2010, the second drug, sibutramine, which acts on the central nervous system, was removed from the market due to increased cardiac risks (FDA 2010b). A few months later, the FDA removed a supplement (Fruta Planta) from the market when it was found to contain that same drug (FDA 2011a). Before the end of 2010, the FDA also denied approval for two new obesity drugs (Qnexa and Lorcaserin) (Pollack 2010a,b) and granted preliminary approval to a third. Providers were hopeful, as the third drug (Contrave) was a combination of two drugs already on the market, but early in 2011, the third drug was sent back for additional testing (FDA 2011b).

Given the overwhelming rise in obesity, there is an ever-growing demand for treatment options. Because millions will take a new weight-loss drug and the risks for adverse reactions are high, the FDA seeks evidence that a drug’s benefits clearly outweigh the risks before allowing it to reach the market.

To ensure safety and efficacy, WHO, NIH, and others emphasize that these drugs are only for weight management conducted with medical supervision and in combination with behavior change therapy. Weight-loss drugs do not offer successful treatment for those unwilling to make changes.

Keep in mind that medications for other problems may also influence weight-reduction efforts. If extra eating stems from feelings of depression, appropriate treatment for depression may aid weight loss. On the one hand, many antidepressants stimulate hunger and could have the opposite effect.

For people living with diabetes, understanding how diabetes medications impact hunger is the key to managing weight. To regulate blood glucose levels, digested food and insulin must be available in the bloodstream at the same time. Biguanides plus the newer oral medications (DPP-4 inhibitors, incretin mimetics, and antihyperglycemic synthetic analogs) help accomplish this without the risk of providing or stimulating excess insulin.

Excessive or improperly timed insulin or insulin-stimulating oral diabetes medications may stimulate hunger and/or the need for extra snacking to avoid hypoglycemia. Two oral medications stimulate increased insulin production. Sulfonylureas are longer acting and taken once or twice a day. Meglitinides are shorter acting but must be taken 5–30 minutes before each meal. People treated with the longer-acting sulfonylurea are more likely to experience hypoglycemia in the late afternoon if they skip or eat too little for lunch. The trade off is more frequent dosing versus more attention to one’s eating schedule.

When treatment with insulin is necessary, understanding the action time of the insulin is essential for coordinating injections with food intake. For example, rapid-acting insulin peaks in 1–2 hours and best matches a balanced meal when taken within 15 minutes of the first bite of food. Among insulin pump users, a common problem is taking extra insulin to lower a high blood glucose level before the insulin already present in the bloodstream has finished working. This often results in hypoglycemia. This experience is usually unpleasant enough that those experiencing it want to feel better right away. There is a strong temptation to treat the hypoglycemia with more food than is needed, setting up a cycle of eating extra food, resulting in hyperglycemia that has to be treated with extra insulin, which leads to more hypoglycemia.

Preventing hypoglycemia does much to limit calorie intake. Treating hypoglycemia appropriately with 15–30 grams of carbohydrate also helps limit calorie intake. Treating hypoglycemia with a fat-containing food (such as peanut butter crackers or a candy bar) adds extra calories, slows the rate of carbohydrate absorption, delays recovery, and often leads to another high glucose reading. For further information about weight issues for those with diabetes, see Diabetes Nutrition Q & A for Health Professionals (ADA 2003).

The hunger that accompanies hyperglycemia itself may subside when diabetes is treated. A well-managed plan for blood glucose control makes a major contribution to weight management.

Apart from drug therapy for obesity, monitoring the side effects of other medications can help everyone avoid unnecessary barriers to weight-loss efforts.

Bariatric Surgery

Bariatric surgery provides another treatment option when dietary, exercise, and behavior change efforts supported by weight-reducing drugs (when available) prove insufficient to reduce health risks.

As the negative consequences of obesity increase and surgical techniques improve, the cost-to-risk ratio has improved, and bariatric surgery has become more common for people whose obesity is a serious health threat. In fact, the number of surgeries increased 10-fold during the six years between 1998 and 2004 (Kulick 2010).

Different surgical methods assist weight loss by reducing stomach size (restricting storage space), by reducing nutrient absorption, and/or by influencing hormones that reduce appetite. By reducing stomach capacity, excess food has nowhere to go, making the consequences of overeating rather unpleasant and reinforcing the habit of eating smaller portions. Surgeries that also reduce absorption result in greater weight loss but also in higher risks for malnutrition.

Guidelines suggest that appropriate patients are those with a BMI ≥40 kg/m2 or a BMI ≥35 kg/m2 with high-risk, life-threatening comorbid conditions (NIDDK 2009). Although surgical procedures are more expensive and come with higher risks for serious complications, preliminary research supports substantial improvement in comorbidities (Ayman 2010) that reduce overall risk (Picot 2009).

Early in 2011, the FDA lowered the cutoff point for the surgery that uses an adjustable gastric banding system. This device, implanted around the upper part of the stomach, limits the amount of food that can be eaten at one time and is now a treatment option for people with a life-threatening comorbid condition (including diabetes) and a BMI ≥30 kg/m2 instead of ≥35 kg/m2. People seeking this surgery must also be willing to make major changes to their lifestyle and eating habits. For those without an obesity-related comorbid condition, the BMI cutoff point for this surgery remains ≥40 (FDA 2011c).

Successful candidates for bariatric surgery have acceptable operative risks and are motivated, willing to become well informed, and willing to participate in continuing programs that support behavior change. The keys to successful bariatric surgery include changing behavior patterns, accessing support systems, and long-term follow-up (Dowd 2005). More specific recommendations address meal timing, portion control, food quality, and the need for exercise. Note that behavior change, exercise, follow-up, and support are the same ingredients required for success using nonsurgical approaches to weight-loss (Franz 2007).

Always Behavior Change

Regardless of the approach to weight loss, behavior change is a required component. Whether it addresses changing a habit, such as late-night snacking, changing food choices, or adding more activity, patients lose a familiar daily activity. They give up a piece of themselves and enter unfamiliar territory. Even drug therapy requires some behavior change to be successful; patients must make sure that they take the medication as prescribed. The experience of weighing less—regardless of how it is accomplished—also changes people’s perceptions of themselves and the way other people respond to them. The following chapters describe a health care model that supports and encourages patients in their efforts to change and offer practical tools for supporting this model’s success.