The Obesity Epidemic: This is your Life Block 10 April, 2004 Arlo Kahn, M.D. UAMS Dept. of Family...

The Obesity Epidemic:This is your Life

Block 10April, 2004

Arlo Kahn, M.D.UAMS Dept. of Family and Preventive Medicine

Arkansas Center for Health ImprovementUAMS College of Public Health

Objectives

What’s happening?

What are patients doing?Diets, drugs, activity

What can physicians do?Counsel, prescribe, cut, advocate

Obesity* Trends Among U.S. AdultsBRFSS, 1988

No Data <10% 10%-14% 15-19% 20-24% 25%

(*BMI 30, or ~ 30 lbs overweight for 5’4” person)

Obesity Trends Among U.S. AdultsBRFSS, 1990

No Data <10% 10%-14% 15-19% 20-24% 25%

Obesity Trends Among U.S. AdultsBRFSS, 1991

No Data <10% 10%-14% 15-19% 20-24% 25%

Obesity Trends Among U.S. AdultsBRFSS, 1992

No Data <10% 10%-14% 15-19% 20-24% 25%

Obesity Trends Among U.S. AdultsBRFSS, 1993

No Data <10% 10%-14% 15-19% 20-24% 25%

Obesity Trends Among U.S. AdultsBRFSS, 1994

No Data <10% 10%-14% 15-19% 20-24% 25%

Obesity Trends Among U.S. AdultsBRFSS, 1995

No Data <10% 10%-14% 15-19% 20-24% 25%

Obesity Trends Among U.S. AdultsBRFSS, 1996

No Data <10% 10%-14% 15-19% 20-24% 25%

Obesity Trends Among U.S. AdultsBRFSS, 1997

No Data <10% 10%-14% 15-19% 20-24% 25%

Obesity Trends Among U.S. AdultsBRFSS, 1998

No Data <10% 10%-14% 15-19% 20-24% 25%

Obesity Trends Among U.S. AdultsBRFSS, 1999

Source: BRFSS, CDC.

No Data <10% 10%-14% 15-19% 20-24% 25%

Obesity Trends Among U.S. AdultsBRFSS, 2000

No Data <10% 10%-14% 15-19% 20-24% 25%

Obesity Trends Among U.S. AdultsBRFSS, 2001

Source: Mokdad A H, et al. JAMA 2003;289:1Source: Mokdad A H, et al. JAMA 1999;282:16;2003;289:1

No Data <10% 10%-14% 15-19% 20-24% 25%

Obesity Trends Among U.S. AdultsBRFSS, 2002

Source: Mokdad A H, et al. JAMA 2003;289:1Source: Mokdad A H, et al. JAMA 1999;282:16;2003;289:1

No Data <10% 10%-14% 15-19% 20-24% 25%

US Adult Obesity Prevalence

  NHANES 1999-2000      Predicted 2010 

Black Women    50.0              57.0%             White Women   30.8               40.0               Black Men        28.7               33.0              

White Men        27.8               37.7     L Roux, MM Yore, NAASO 2003 Annual Scientific Meeting          

Actual Causes of Death in the United States, 1990

Source: McGinnis JM, Foege WH. JAMA 1993;270:2207-12.

400,000

300,000

100,000 90,000

30,000 20,000

Tobacco Diet/Activity Alcohol Microbialagents

Sexualbehavior

Illicit use ofdrugs

Actual Causes of Death in the United States, 2000Tobacco:

435,000 deaths Poor diet and physical inactivity

400,000 deaths

“Poor diet and physical inactivity may soon overtake tobacco as the leading cause of death”

Mokdad, AH et al. JAMA. 2004;291:1238-1245

RAND Research

Obesity is linked to rates of chronic illnesses higher than living in poverty, and much higher than smoking or drinking.

Sturm R. The Effects of Obesity, Smoking, and Problem Drinking on Chronic Medical Problems and Health Care Costs. Health Affairs. 2002;21(2):245-253.

Sturm R, Wells KB. Does Obesity Contribute As Much to Morbidity As Poverty or Smoking? Public Health. 2001;115:229-295

The Risks of Overweight

coronary heart disease, congestive heart failure

cancer of breast, prostate, colon, uterus, liver, kidney, pancreas, esophagus

stroke Arthritis, gout gallbladder disease incontinence, poor female reproductive

health sleep apnea, asthma, other respiratory

problems hypertension, diabetes mellitus, high

cholesterol

The Costs: 2000

Cost of obesity in U.S.: $117 Billion (>17% increase from

1996)

Cost of obesity in Arkansas: ~$1.2 Billion

9.4 percent of the national health care expenditures in the United States are directly related to obesity and physical inactivity

Obesity in Arkansas

7th highest rate of physical inactivity 84.6% of Arkansas adults are at risk for health problems related to lack of exercise21 percent increase in the number of Arkansans who have diabetes from 1993 – 2000Type 2 diabetes at ACH

2 cases in mid 90’s >100 cases last year

Adult BMI Chart

5'45'4""

HeightHeight

Weight (lbs)Weight (lbs)

5'25'2""

5'05'0""

5'105'10""

5'85'8""

5'65'6""

6'06'0""

6'26'2""

120120 130130 150150 160160 170170 180180 190190 200200 210210 220220 230230 240240 250250140140 260260 270270 280280 290290 300300

6'46'4""

Generation XXL

Boys: 2 to 20 years

BMI BMI

BMI BMI

Girls: 2 to 20 years

Percentage of U.S. Children and

Adolescents Who Were Overweight*

0

2

4

6

8

10

12

14

16

1963-70 1971-74 1976-80 1988-94 1999

Ages 12-19

Ages 6-11

1963-70 data are from 1963-65 for children 6-11 years of age and from 1966-70 for adolescents 12-17 years of age* >95th percentile for BMI by age and sex based on 2000 CDC BMI-for-age growth chartsSource: National Center for Health Statistics

Percentage of U.S. Children and

Adolescents Who Were Overweight*

0

2

4

6

8

10

12

14

16

1963-70** 1971-74 1976-80 1988-94 1999

Ages 12-19

Ages 6-11

5

4

14

13

* >95th percentile for BMI by age and sex based on 2000 CDC BMI-for-age growth charts**Data are from 1963-65 for children 6-11 years of age and from 1966-70 for adolescents 12-17 years of ageSource: National Center for Health Statistics

84th General Assembly Act 1220 of 2003

AN ACT TO CREATE A CHILD HEALTH ADVISORY COMMITTEE;

TO COORDINATE STATEWIDE EFFORTS TO COMBAT

CHILDHOOD OBESITY AND RELATED ILLNESSES; TO

IMPROVE THE HEALTH OF THE NEXT GENERATION OF

ARKANSANS; AND FOR OTHER PURPOSES.

The Arkansas BMI Initiative

Act 1220 : Beginning in the 2003-2004 school

year, each school district shall annually Measure the BMI of each K-12th grade student and report it to parentExplain to parents the possible health effects of body mass index, nutrition and physical activity

The NumbersIn May, 2004 BMI health letters will go out to parents of 450,000 Arkansas public school students.

Based on data from the Cambridge schools, ~34% of students may be in the “overweight” or “risk of overweight” categories, with about 17% in each category.

In the Cambridge study on response to BMI report cards (1396 elementary students), parents of 25% of children in these categories reported that they planned to seek medical service for this problem.

3. If Arkansas numbers are similar, it is possible that parents of 38,000 students will seek medical care related to the BMI report. (450,000 x .34 x.25 = 38,250.)

Rationale for the BMI Initiative

Treatment of adult obesity has had less than satisfactory outcomes. Prevention is most promising.Overweight school-age children have a 50% probability of becoming obese adults.Overweight adolescents have a 70-80% probability of becoming obese adults.Many children do not make regular doctor visits, and when they do, BMI is not routinely checked. (2002 study found that less than 20% of pediatricians were checking BMI.)While parents often recognize when their children are extremely overweight, many parents do not recognize less extreme overweight that still poses health and emotional risks to their kids.Many parents do not know the risks of overweight.

Rationale for using BMI in Children and Adolescents to Assess for

Weight-related Risks

95th percentile for age corresponds to BMI of 30 in young adult (obesity)85th percentile for age corresponds to BMI of 25 in young adult (overweight) Compared with DEXA, 95% of children with BMI >95th percentile had increases in body fatBMI percentile predicts CVD risk: 60% of 5-10 year old kids>95th percentile have at

least 1 additional risk, 15% have 2 or more

BMI in Children and Adolescents:Limitations

Weight and height do not directly measure body fatnessAdditional criteria are necessary to determine whether someone with BMI>95th percentile is overfat (e.g. tricep skinfold thickness) as opposed to overweight because of increased muscle or bone massChanges in BMI over time may be as important as single reading

What are your patients doing about obesity?

29% of men and 44% of women trying to lose weight

About 20% of report restricting calories or increasing physical activity

What Can Physicians Do

CounselDietsDrugsSurgeryAdvocacy

Treating Obesity Without Frustration

GoalLearn how to work with obese patients in a manner that is effective, minimizes physician frustration, shows respect for the patient and maintains good communication

PROBLEM: CAD and Type II DM

S: Ms. X is a 35 year old who was diagnosed as having diabetes sometime in the last several months at the time of her admission for angioplasty with two coronary stents placed in her LAD. She is currently taking 10 mg of Glipizide b.i.d. and 12 units of Humulin 100 at night. She says that she checks her BS up to 4 times q.d., and they are always in the upper 100s and lower 200s. She takes Monopril 10 mg. q.d., Lipitor 10 mg. b.i.d. , aspirin 325 mg. enteric coated, and Prozac 40 mg. q.d. She has lost l5 lbs. since her diagnosis, approximately 3 months ago, but has not lost any weight recently. Smokes 1ppd.

O: Current weight is 235#. Height is 5’4”. BMI 40.5.

Assuming you want to address her obesity, how would you proceed?

The Good Old 4-A Technique

ASKADVISEASSISTARRANGE

ASK

Assess readiness to change“Do you want to work on

losing weight”?

If ready, assess previous and current efforts and obstacles

When asked if she is interested in addressing any of her lifestyle issues at this time she said that she would be interested in addressing her weight.

She is supposed to be on a l500 calorie diet, but she has never really counted calories, so she is not sure what she is actually consuming.

She is not able to identify any single foods that she eats frequently that she thinks are bad for her. She drinks 2% milk, and apparently has several servings a day. She was unaware that this is actually high fat milk.

She is supposed to be exercising about 30 minutes 3 times a week, but rarely does more than twice a week.

She doesn't like exercise and doesn't like dieting.

She feels that being asymptomatic with regard to respiratory, cardiovascular, GI, and musculoskeletal systems reinforces her lack of motivation.

Readiness to Change

Precontemplation (not interested)Contemplation (6 months)Preparation (within a month)Action (working on it)Maintenance

Obstacles

Unaware of current intakeUnaware of high calorie foodsDoesn’t like exercise or dietingFeels fine

ADVISE

Give brief personalized advice:

her risks of overweightbenefits to her of controlling weight

ASSIST

How to assist depends on Stage of Readiness to Change!!!

Assist(Readiness Stage: Preparation)

Provide educational materials Test Motivation: Give diet diary (3-7

day) Decrease obstacles

– Inform of support programs available in the community

– Counsel or refer as needed for counseling

She is not willing to go to Weight Watchers.

She is willing to keep a diet diary for a week and return then to review it.

ArrangePlan: 1) Discussed motivation and personal value of

weight loss. She is willing to do a diet diary for a week and return in 1 week with those results, at which time we will review the diary. In the meantime, she says that she will also be willing to increase her walking to 3 times a week.

2) I have referred her to Dr. Z for counseling to examine possibilities for increasing motivation to improve her lifestyle.

Treating Obesity Without Frustration

Assess readiness to changeAssess barriers to changeUse appropriate tools to assess motivationAddress obstacles creativelyDetermine whether referral is appropriate and to whom patient should be referredFrequent follow-up for patients in preparation, action, or maintenance

Pearls for Treating KidsSelf-monitoring is one of most helpful tools. Have them record physical activity and diet on daily basis, weight every 2-4 weeks. Review when patients come back and give praise where appropriate.Work on stimulus controlSet limits on screen time (2 hrs/ day). No TV while eating. Remove snacks from view. Put out fruits and vegetables. No seconds. Regular meal times including breakfast. Fist size portions only.

Physical activity-anything that raises breathing and heart rates (brisk walking, bicycling, dancing).Work up to one hour/day.Nutrition- increase fruits and vegetables, skim and 1% milk. Decrease sugar drinks and high saturated and trans fat foods (fast food and candies)Give children attention and provide role models. Eat and play together.If above fails, portion control, poor compliance or emotional problems may be the answer. Support groups can be helpful if available.Referral is appropriate if co-morbidities are found that do not respond to efforts above and for discovery of abuse or other severe psychopathology.

Diets and Drugs for Obesity: A Critical

Review

AHA Guidelines for Healthy Diets

Protein: 15-20% of calories not excessive (50-100g/d) proportional to carbohydrate and fatCarbohydrates: ~55% of calories Minimum of 100g/d

Fat: ~30% of calories, <10% sat fatProtein foods should not contribute excess total fat, sat fat or cholesterolDiet should provide adequate nutrients and support dietary compliance

St. Jeor ST, etal. Circulation 104:1869-74, 2001.

A particular food or nutrient causes weight loss. Usually low in calories. May lead to protein calorie malnutrition leading to breakdown of lean muscle mass.

Right for your typeBeverly HillsFit for LifeGrapefruit DietCabbage diet

Low calorie, generally levels of 1200 or less.

Jenny CraigWeight WatchersSlim FastRichard Simmons

Limit carbohydrates; increase protein and sometimes fat.

Atkin’s DietThe ZoneSugar BustersProtein PowerCarbohydrate Addict’s diet

DescriptionDiets

Categorization of Diets by CHO and Fat

Dean Ornish Diet<10% Fat

Pritikin Diet<15% Fat

Weight Watchers, Jenny Craig, DASH diet, Food Guide Pyramid

55-60% CHO <30% Fat

The Zone Diet40% CHO 30% Fat

Carbohydrate Addicts Diet< 30% CHO

Atkins (20-60g CHO), Protein Power (<60g CHO), VLCD-protein sparing modified fast

< 20% CHO

Riley RE. Clinics in Sports Medicine. 18(3):691-701, 1999.

Atkins Diet Revolution

Strict limits on carbs enable body to burn fat. Insulin is “single most significant determinant of weight.”

Ketotic diet. Limited food choices. High in fat and saturated fat. Low in fiber, vit D, Ca, K, Mg, Mn.Available supplements include chromium picolinate, carnitine, coenzyme Q10, fatty acids.

14 days = 53% fat/d, 23% sat fat/d

14 days = 28g/d (5%)Ongoing = 33g/dMaintenance = 128g/d

14 days = 125g/d (36%)Ongoing = 161g/d (35%)Maintenance = 110g/d (24%)

Safety??

Fat

Carbs

Protein

Riley RE. Clinics in Sports Medicine. 18(3):691-701, 1999.

Rap

The Zone

40:30:30 keeps insulin levels in “The Zone”.Recommends drinking water and exercising. Recommends 200 IU vitamin E.

Requires strict proportions of protein, fat and carb (40:30:30) in all meals and snacks.

Menus not appealing to many with low vegetable portions. Low in whole grains, calc.

29% fat/d; 4% sat fat/d

135g/d (36%)

127g/d (34%)

Safety??

Fat

Carbs

Protein

St. Jeor ST, etal. Circulation 104:1869-74, 2001.

Riley RE. Clinics in Sports Mediicne. 18(3):691-701, 1999.

Rap

Protein Power

Limiting carbs (moderate fat and adequate protein) lowers insulin. Insulin causes obesity.

Rigid rules, CHO must be chosen carefully.Low in Ca, fiber, Cu, Mn. High in fat and sat fat; low in whole grains and calcium. Recommends vitamin/mineral supplement.Recommends exercise esp. strength training.

54% fat/d; 18% sat fat/d

20 to 56g/d (16%)

91g/d (26%)

Safety??

Fat

Carbs

Protein

Riley RE. Clinics in Sports Mediicne. 18(3):691-701, 1999.

Rap

High Protein: Effects

Diuresis (limited to 1st week)Mobilization of glycogen stores – cause weight loss of ~ 1 kgGeneration of ketones

Reductions in caloric contentAppetite suppression from ketosisNo studies have demonstrated advantages of ketotic diet

Denke M. Am J Cardiology 88(1):59-61, 2001.

St.Jeor ST, et al. Circulation 104:1869-1874, 2001.

High protein: Metabolic Effects

Ketosis dehydration, constipation and kidney stonesfatigue??? alter cognitive functioning

High Saturated FatIncreases in LDL-C and TC

Low Fruits, Vegetables and GrainsDeficient in micronutrients (Vitamin B, calcium, K) and phytochemicals

Increases in serum uric acid Denke M. Am J Cardiology 88(1):59-61, 2001.

St.Jeor ST, et al. Circulation 104:1869-1874, 2001.

Westman EC. Et al. Am J Med. 113(1): 30-6, 2002.

Other possible effectsKidney stonesOsteoporosisChronic renal insufficiency

Sugar Busters

Refined carbs cause obesity by raising blood sugar. Eliminates high glycemic index foods like white rice, potatoes, carrots, white bread and corn.

Eliminates many foods with carbs. Daily menus range from 7 to 44 g sat fat. Discourages eating fruit with meals. Limits water because “excess fluid dilutes digestive juices.”Low in Ca, vit D, vit E, Cu and K. Downplays need to exercise.

21% fat/d; 4% sat fat/d

114g/d (52%)

71g/d (27%)

Safety??

Fat

Carbs

Protein

Rap

South Beach Diet

Phase 1: two weeks. Most should see a rapid weight loss of between 8 – 13 pounds. Most restrictive.

Phase 2: until reach goal weight. Weight loss 1-2 pounds per week. Foods that were restricted in re-introduced into the diet.

Phase 3: for life. Restrictions: avoid highly processed food that contains ‘bad’ carbs and ‘bad’ fats and try and stick to the food that contains the ‘good’ ones.

StructureStudies suggest that adding structure to dietary recommendations improves weight loss in the behavioral treatment of obesity. Structure reduces the effort required for adherence, and eliminates much of the decision making, temptation, and guesswork involved in making healthy food choices.

Weight Watchers

Practical adviceGroup techniquesFood varietyModerate protein, low fatLimits refined sugars and EtOHStresses activity

GroupsVery structuredWeekly fees

Structured Meal Plans

Providing patients with structured meal plans and grocery lists produced just as great a weight loss at 6 months (13.7%) as did providing them with portion-controlled servings of food (13.5%).

The findings of this study indicate that specifying what foods and what amounts patients should eat improves weight loss, but that providing the food has no additional effect.

Protein – Sparing Modified Fast (Optifast, Medifast)

Calorie intake usually <900/dMinimize loss of lean body mass by having 70-90g/d proteinLCD = ~800 cal/dVLCD = <800 cal/dUsually liquidMedical supervision needed

Low Calorie Diets

Reduce total body weight by average of 8% over 3-12 monthsGreater initial loss with VLCD No difference between VLCD and LCD over long term (> 1 year)

NHLBI. Clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults. 1998.

Maintenance

After losing 10% of their weight or more with 6 months of treatment, patients typically regain approximately one half of that weight within 1 year and return to their baseline weight within 5 years if they receive no further treatment

PharmacotherapyNHLBI:

“FDA-approved pharmacotherapy can be helpful adjunct for treatment of obesity in some patients.”Consider if lifestyle changes do not promote weight loss after 6 monthsNet average loss attributable to drugs 2 to 10 kg usually within first 6 months

NHLBI. Identification, evaluation and treatment of overweight and obesity in adults. October 2000.

NHLBI: Limit drugs to BMI > 30 or BMI >27

w/concomitant risk factors or disease Discontinue if patient does not lose 2

kg in first 4 weeks F/U visits include weight & BP check,

pulse, lab tests, discuss side effects and answer questions 2 - 4 weeks Monthly for 3 months q 3 months for 1st year

NHLBI. Identification, evaluation and treatment of overweight and obesity in adults. October 2000.

Haddock CK et al. Intl J of Obesity. 26:252-273, 2002.

Obesity DrugsAppetite suppressants

Noradrenergic (Schedule IV)

Phentermine (Adipex, Fastin)Diethylpropion (Tenuate)

Noradrenergic (Schedule III)

Benzphetamine (Didrex)Phendimetrazine (Bontril)

Serotonergic Fenfluramine, dexfenfluramine

Mixed Noradrenergic & SerotonergicSibutramine (Meridia)

Nutrient absorption reducers Lipase inhibitor

Orlistat (Xenical)

Sibutramine (Meridia)Contraindicated: CAD, CHF, cardiac arrhythmias or strokeSide Effects: hypertension, arrhythmia, tachycardia pulse and BP should be checked before treatment and every 2 weeks in the 1st 3 months and every 1-3 months thereafter Fernstrom MH. Postgraduate Med. June 2001,

10-18.

Bray GA. Nutrition. 16(10):953-60, 2000.

Carek PJ, Dickerson LM. Drugs. 57(6):883-904, 1999.

Wooltorton E. CMAJ. 166(10):1307-08, 2002.

Side EffectsCommon

HeadacheDry mouthConstipationInsomnia

Stop treatment in patients who experience:

an increase in heart rate of 10 beats/min an increase in either SBP or DBP of >10 mmHg in 2 consecutive visits

Orlistat

Lipase inhibitor that reduces fat absorption by ~30% resulting in reduction in energy intakeInhibits digestion of dietary triglycerides, decreases absorption of cholesterol and lipid-soluble vitamins

Fernstrom MH. Postgraduate Med. June 2001, 10-18.

Bray GA. Nutrition. 16(10):953-60, 2000.

Carek PJ, Dickerson LM. Drugs. 57(6):883-904, 1999.

Side Effects

GI side effects due to inhibition of fat absorption

pain, fecal urgency, liquid stools, flatulence with discharge, oily spotting

Multivitamin recommended because of reduction in absorption of fat soluble vitamins (esp. A & E)

Summary: Meta-analysis

Placebo subtracted weight losses for single drugs never exceeded 4.0 kgNo drug or class of drug exhibits clear superiorityIncreasing length of drug treatment does not lead to more weight loss

Haddock CK, et al. Int J Obesity. 26:262-73, 2002.

Surgery2001 47,000 2002 63,0002003 98,000NIH Criteria:

Well informed and motivated patientBMI>40 orBMI>35 with co-morbidities

Mortality: 1-2%Effectiveness: >50% excess weight loss at

14 years

Evidence-based Strategies to Increase Physical

ActivityThe Guide to Community Preventive Services, MMWR 2001

Creating or Improving Access to Places for Physical ActivityProviding Social Support in Community SettingsCommunity-wide Campaigns to Promote Physical ActivityPoint-of-Decision Prompts that Encourage People to Use the StairsHealth Behavior Change Programs Adapted for Individual NeedsChild-specific information to parents regarding their child’s body mass index percentile

Weight Control Diets: Key Points

E=mc2

Time mattersCommitment is required Structure helpsP.T. Barnum was rightHealthy weight is only a part of good nutrition

THE END

Opportunities

Inform parents of their children’s risks and what they can doAlert public and policy makers of the epidemicEncourage communities and schools to address the problemEstablish Arkansas as a leader in health initiativesAttract attention of foundations and other funding agenciesAccomplish population based longitudinal assessments: Age, race, poverty, rural/urban, physical activity (Childhood obesity “Framingham” study)

ChallengesObtain accurate measurements of 450,000 kids in <1 yearDevelop and implement standardized protocols (equipment, technique, recording) Maintain confidentiality and avoid stigmatizing childrenManage the dataDevelop and deliver health letter to parents Educate healthcare providers in how to manage “at risk” childrenAddress political concerns and media reports

Obesity and Mortality Risk

Bray GA, et al. Diabetes Metab Rev. 1988;4:653-679.

Beverage Intake Among Adolescents

Aged 11-18, 1965-1996

SOURCE: Cavadini C et al. Arch Dis Child 2000;83:18-24 (based on USDA surveys)

0

200

400

600

800

1000

1200

1400

1600

1965 1977 1989 1996

Per

cap

ita

gra

ms

con

sum

ed p

er d

ay

Boys Girls

(Soft drinks, diet soft drinks, and fruit drinks)

4th highest rate of overweight 77 percent increase in the number

of Arkansans who were obese from 1991 to 2000

60% of adult Arkansans were overweight or obese in 2000 (67% of men, 53% of women, 67% of non-whites, 56% of whites)

Obesity in Arkansas

Meal Replacements

113 overweight pre-menopausal women divided into 3 groups1. Sessions with dietitian 2. Sessions with dietitian plus Slimfast3. 10-15 min visits w/MD or RN plus

SlimfastGroup 2 lost significantly more weightGroup 3 was as effective as group 1

Ashley JM, et al. Arch Intern Med. 161:15991604, 2001.

Reducing the guesswork that accompanies calorie counting Increasing the structure of an eating plan can help patients improve their chances of successful weight loss. Providing patients with specific low-calorie eating plans, grocery lists, and instructions for food preparationEncouraging the use of portion-controlled meal-replacement products for 1 or 2 meals per day. Both of these methods have been shown to be effective for weight loss, and preliminary evidence suggests that meal replacements may also facilitate long-term weight control.

Sibutramine: Effectiveness

STORM (Sibutramine Trial of Obesity Reduction and Maintenance)

safety established over 2 yearsdose related effects – start at 10 mg/d1047 adults with BMI 30 – 401, 5, 10, 15, 20 or 30 mg/d1200 cal/d for women; 1500 cal/d for mencounseling from RD

James WP, etal. Postgrad Med. June 2001, 19-28.

Orlistat Studies

44 obese men & women, diet & 12 wks of orlistat 50 mg tid vs. placebo

4.3 kg vs. 2.1 kg weight loss

188 pts, 10, 60 or 120 mg tid orlistat2.98 kg placebo3.61 kg 30-mg; 3.69 kg 180-mg; 4.74 kg 360-mg

46 obese men & women, 120-mg tid & low-fat diet – maximum change at 6 months

8.6 kg vs. 5.5 kg

Orlistat Studies

743 pts, multi-center, randomized, placebo-controlled trial w/BMI 27-47At 12 months,

Weight loss = 22.7# vs 13.4#59.2% vs. 47.1% lost 5% of body weight; 38.8% vs 17.7% lost 10% of body weight

24 months of orlistat vs placebo57.1% vs. 37.4% maintained weight loss greater than 5% of body weight

Fernstrom MH. Postgraduate Med. June 2001, 10-18.

6 US studies of 2.5 years f/u of diet + behavior therapiesWeight regain

61-86% at 2.5-3.5 years75-121% at 5 years

Glazer G. Arch Int Med 161(5):1814-24, 2001.