Dietary therapy for obesity

 

The optimal management of overweight and obesity requires a mixture of diet, exercise, and behavioral modification. additionally, some patients eventually require pharmacologic therapy or bariatric surgery. the danger of overweight to the topic should be evaluated before beginning any treatment program. Selection of treatment can then be made employing a risk-benefit assessment. the selection of therapy depends on several factors including the degree of overweight or obesity and patient preference.
This topic will review the dietary therapy of obesity. Other aspects of treatment are discussed separately.


GOALS OF WEIGHT LOSS

— it’s important to line goals when discussing a dietary weight loss program with a personal patient. An initial weight loss goal of 5 to 7 percent of weight is realistic for many individuals.
• The first goal for any overweight individual is to forestall further weight gain and keep weight stable (within 5 pounds of its current level).
• The goal of the clinician is to spot and review with the patient a sensible weight loss goal. Most patients have a weight loss goal of 30 percent or more below current weight, which is unrealistic
• A successful program will result in a weight loss of quite 5 percent of initial weight A weight loss of quite 5 percent can reduce risk factors for upset, like dyslipidemia, hypertension, and DM In the Diabetes Prevention Program, a multi-center trial in patients with impaired glucose tolerance, weight loss of seven percent reduced the speed of progression from impaired glucose tolerance to diabetes by 58 percent .
• Loss of 5 percent of initial weight and maintenance of this loss may be a good medical result, whether or not the topic doesn’t reach his or her “dream” weight.
• Although a very difficult goal to realize, a body mass index (BMI) between 20 and 25 kg/m2 puts the topic within the lowest risk category

DIETARY ENERGY


Rate of weight loss

— the speed of weight loss is directly associated with the difference between the subject’s energy intake and energy requirements. Reducing caloric intake below expenditure ends up in a predictable initial rate of weight loss that’s associated with the energy deficit However, prediction of weight loss for a private subject is difficult thanks to marked intersubject variability in initial body composition, adherence, and energy expenditure Food records are often inaccurate. Most normal-weight people under-report what they eat by 10 to 30 percent, while overweight people under-report by 30 percent or more additionally, energy requirements are influenced by fidgeting, gender, age, and genetic factors ]. As examples:

• Men lose more weight than women of comparable height and weight after they adjust to eating any given diet because men have more lean body mass, less percent body fat, and so higher energy expenditure.
• Older subjects of either sex have a lower energy expenditure and thus slenderize more slowly than younger subjects; rate declines by approximately 2 percent per decade (about 100 kcal/decade)
• The importance of genetic factors is illustrated by a study of identical male twin pairs who were overfed to induce weight gain Twelve twin pairs were overfed by 1000 kcal/day for 84 of 100 days. The degree of weight gain at a continuing dietary caloric increment varied widely among the dual pairs (from 4.3 to 13.3 kg), in fact, there was 3 times the variance for both weight and fat mass among the dual pairs compared therewith within the dual pairs.
Approximately 22 kcal/kg is required to take care of a kilogram of weight in an exceedingly normal adult. Thus, the expected or calculated energy expenditure for a lady weighing 100 kg is approximately 2200 kcal/day. The variability of ±20 percent could give energy needs as high as 2620 kcal/day or as low as 1860 kcal/day. a median deficit of 500 kcal/day should end in an initial weight loss of roughly 0.5 kg/week (1 lb/week). However, after three to 6 months of weight loss, energy expenditure adaptations occur, which slow the bodyweight response to a given change in energy intake, thereby diminishing ongoing weight loss
There are several methods of formally estimating energy expenditure; we recommend using the WHO criteria This method allows a right away estimate of resting rate (RMR) and calculation of daily energy requirement. The low activity level (1.3 x RMR) includes subjects who lead a sedentary life. The high activity level (1.7 x RMR) applies to those in jobs requiring toil or patients with regular daily workout programs

Maintenance of weight loss

— it’s important for the overweight subject to know that achieving and maintaining weight loss is created difficult by the reduction in energy expenditure that’s induced by weight loss Weight loss maintenance is additionally difficult due to changes within the peripheral hormone signals that regulate appetite. Gastrointestinal peptides, like ghrelin, which stimulates appetite, and gastric inhibitory polypeptide, which can promote energy storage, increase after diet-induced weight loss. Other circulating mediators that inhibit intake (eg, leptin, peptide YY, cholecystokinin, pancreatic polypeptide) decrease. These hormonal adaptations favoring weight gain persist for a minimum of one year after diet-induced weight TYPES OF DIETS — the final consensus is that excess intake of calories from any source, related to a sedentary lifestyle, causes weight gain and obesity. The goal of dietary therapy, therefore, is to decrease energy intake from food. Conventional diets are defined as those below energy requirements but above 800 kcal/day These diets comprise four groups: • Balanced low-calorie diets/portion-controlled diets

• Low-fat diets

• Low-carbohydrate diets

• Mediterranean diet

• Fad diets (diets involving unusual combinations of foods or eating sequences)

Commercial weight loss programs and internet-based programs are discussed elsewhere .) Balanced low-calorie diets — Planning a diet requires the choice of a caloric intake so selection of foods to fulfill this intake. it’s desirable to eat foods with adequate nutrients additionally to protein, carbohydrate, and essential fatty acids. Thus, weight-reducing diets should eliminate alcohol, sugar-containing beverages, and most highly concentrated sweets because they rarely contain adequate amounts of other nutrients besides energy. Breakdown of some protein is to be expected during weight loss. When weight increases as a results of overeating, approximately 75 percent of the additional energy is stored as fat and therefore the remaining 25 percent as lean tissue. If the lean tissue contains 20 percent protein, then 5 percent of the additional weight gain would be protein. Thus, it should be anticipated that in weight loss, a minimum of 5 percent of weight loss are protein. A desirable feature of any calorie-restricted diet, however, is that it leads to very cheap possible loss of protein, recognizing that this can not be but 5 percent of the load that’s lost. Portion-controlled diets — One simple approach to providing a calorie-controlled diet is to use individually packaged foods, like formula diet drinks using powdered or liquid formula diets, nutrition bars, foodstuff, and pre-packaged meals which will be stored at temperature because the main source of nutrients. Frozen low-calorie meals containing 250 to 350 kcal/package are often a convenient and nutritious thanks to try this. we’ve often recommended the utilization of formula diets or breakfast bars for breakfast, formula diets or a frozen lunch entree for lunch, and a frozen calorie-controlled entree with additional vegetables for dinner. during this way, it’s possible to get a calorie-controlled 1000 to 1500 kcal per day diet. In one four-year study this approach resulted in early initial weight loss, which then was maintained I don’t recommend the utilization of formula diets alone because they are doing not provide adequate nutritional variety. Low-fat diets — Low-fat diets are another standard strategy to assist patients reduce, and the majority dietary guidelines recommend a discount within the daily intake of fat to 30 percent of energy intake or less in an exceedingly meta-analysis of trials comparing low-fat diets (typically 20 to 25 percent of energy from fats) with a bearing group consuming a usual diet or a medium fat diet (usually 35 to 40 percent of energy), there was greater weight loss (approximately 3 kg) with low-fat compared with moderate fat diets additionally, one report noted that individuals who successfully keep their weight reduced adopt three strategies, one in all which is eating a lower fat diet A low-fat dietary pattern with healthy carbohydrates isn’t related to weight gain. This was illustrated by the Women’s Health Initiative Dietary Modification Trial of 48,835 postmenopausal women over age 50 years who were randomly assigned to a dietary intervention that included group and individual sessions to push a decrease in fat intake and increases in fruit, vegetable, and grain consumption (healthy carbohydrates), but failed to include weight loss or caloric restriction goals, or a sway group which received only dietary educational materials After a mean of seven.5 years of follow-up, the subsequent results were seen:

• Women within the intervention group lost weight within the first year (mean of two.2 kg) and maintained lower weight than the control women at 7.5 years (difference of 1.9 kg at one year, and 0.4 kg at 7.5 years).

• No tendency toward weight gain was seen within the intervention group overall, or when stratified by age, ethnicity, or body mass index.

• Weight loss was associated with the amount of fat intake and was greatest in women who decreased their percentage of energy from fat the foremost. A similar, but lesser trend was seen with increased vegetable and fruit intake. A diet may be implemented in two ways. First, the dietitian can provide the topic with specific menu plans that emphasize the employment of reduced fat foods. in concert guideline, if a food “melts” in your mouth, it probably has fat in it. Second, subjects will be instructed in counting fat grams as another to counting calories. Fat has 9.4 kcal/g. it’s thus very easy to calculate the amount of grams of fat an issue can eat for any given level of energy intake. Many experts recommend keeping calories from fat to below 30 percent of total calories. In practical terms, this suggests eating about 33 g of fat for every 1000 calories within the diet. For simplicity, i take advantage of 30 g of fat or less for every 1000 kcal. For a 1500-calorie diet, this is able to mean about 45 g or less of fat, which might be counted using the nutrition information labels on food package

Low-carbohydrate diets

— Proponents of low-carbohydrate diets have argued that the increasing obesity epidemic is also partially thanks to low-fat, high-carbohydrate diets. But this could be dependent upon the kind of carbohydrates that are eaten, like energy dense snacks and sugar or high fructose containing beverages. The carbohydrate content of the diet is a very important determinant of short-term (less than two weeks) weight loss. Low (60 to 130 grams of carbohydrates) and really low-carbohydrate diets (0 to <60 grams) are popular for several years Restriction of carbohydrates ends up in glycogen mobilization and, if carbohydrate intake is a smaller amount than 50 g/day, ketosis will develop. Rapid weight loss occurs, primarily because of glycogen breakdown and fluid loss instead of fat loss. Low and really low-carbohydrate diets are simpler for short-term weight loss than low-fat diets, although probably not for long-term weight loss. A meta-analysis of 5 trials found that the difference in weight loss at six months, favoring the low carbohydrate over low fat diet, wasn’t sustained at 12 months Low-carbohydrate diets may have another beneficial effects with reference to risk of developing type 2 DM, coronary heart condition, and a few cancers, particularly if attention is paid to the kind additionally because the quantity of carbohydrate. A low-carbohydrate diet is implemented in two ways, either by reducing the whole amount of carbohydrate or by consuming foods with a lower glycemic index or glycemic load Glycemic index and cargo are reviewed separately. .) If a low-carbohydrate diet is chosen, healthy choices for fat (mono- and polyunsaturated fats) and protein (fish, nuts, legumes, and poultry) should be encouraged due to the association between saturated fat intake and risk of coronary heart condition. During 26 years of follow-up of ladies within the Nurses’ Health Study and 20 years of follow-up of men within the Health Professionals’ Follow-up Study, low carbohydrate diets within the highest versus lowest decile for vegetable proteins and fat were related to lower all-cause mortality (HR 0.80, 95% CI 0.75-0.85) and cardiovascular mortality (HR 0.77, 95% CI 0.68-0.87 ]. In contrast, low carbohydrate diets within the highest versus lowest decile for animal protein and fat were related to higher all-cause (HR 1.23, 95% CI 1.11-1.37) and cardiovascular (HR 1.14, 95% CI 1.01-1.29) mortality High protein diets — Some popular books recommend high protein diets In one trial, low-fat diets with 12 percent and 25 percent protein content were compared. Weight loss over six months was greater with the upper protein diet (9 versus 5 kg), but the difference was not significant at 12 and 24 months Higher protein diets may improve weight maintenance, as illustrated by the results of a study of 60 subjects randomly assigned to an occasional fat, high protein versus low-fat, high-carbohydrate diet after completing a four week very low calorie diet Among the topics who completed the three-month study (n = 48), the high protein diet group had significantly better weight maintenance (between group difference of two.3 kg). High dietary protein intake, thanks to its acid-producing load, increases urinary calcium excretion (with potential risk for bone loss and calcium stone formation) Urinary calcium excretion does appear to extend when dietary intake of protein increases ], and this might pose a long-term risk for nephrolithiasis. However, two small randomized trials that checked out bone metabolism found evidence that increased dietary protein may decrease bone resorption ]. one in all the trials found that increased intestinal absorption of calcium was primarily liable for the increased urinary excretion of calcium which the excreted calcium wasn’t coming from bone Mediterranean diet — The term Mediterranean diet refers to a dietary pattern that’s common in olive-growing areas of the Mediterranean area. Although there’s some variation in Mediterranean diets, there are some common components that include a high level of monounsaturated fat relative to saturated; moderate consumption of alcohol, mainly as wine; a high consumption of vegetables, fruits, legumes, and grains; a moderate consumption of milk and dairy products, mostly within the kind of cheese; and a comparatively low intake of meat and meat products. A meta-analysis of 12 studies involving eight cohorts found that a Mediterranean diet was related to improved health status and reductions in overall mortality, cardiovascular mortality, cancer mortality, and incidence of brain disease and Alzheimers Very low-calorie diets — Diets with energy levels between 200 and 800 kcal/day are called “very low-calorie diets,” while those below 200 kcal/day are often termed starvation diets. the idea for these diets was the notion that the lower the calorie intake the more rapid the load loss, because the energy withdrawn from body fat stores may be a function of the energy deficit. Starvation is that the ultimate very obesity diet and ends up in the foremost rapid weight loss. Although once popular, starvation diets are now rarely used for treatment of obesity. Very low-calorie diets haven’t been shown to be superior to standard diets for long-term weight loss. in a very meta-analysis of six trials comparing very low-calorie diets with conventional low-calorie diets, short-term weight loss was greater with very low-calorie diets (16.1 versus 9.7 versus percent of initial weight), but there was no difference in long-term weight loss (6.3 versus 5.0 percent like all diets, very low-calorie diets initially lead to substantial protein loss that diminishes with time. Other expected effects include reduction in pressure and improvement in hyperglycemia in diabetic patients.

• Subjects adhering to very low-calorie diets usually have a fall in force per unit area, especially during the primary week. Antihypertensive drugs, especially calcium channel blockers and diuretics, should usually be discontinued when a awfully low calorie diet is begun unless moderate to severe hypertension is present.

• Most diabetic patients eating very low-calorie diets have marked improvement in hyperglycemia. blood sugar concentrations fall within the primary one to 2 weeks, and remain lower as long because the diet is sustained. Those patients taking but 50 units of insulin or an oral hypoglycemic drug will usually be able to discontinue therapy ]. The side effects of very low-calorie diets include hair loss, thinning of the skin, and coldness. These diets are contraindicated for lactating and pregnant women, and in children who require protein for linear growth. like all diets, there’s increased cholesterol mobilization from peripheral fat stores, thus increasing the chance of gallstones. Very low-calorie diets should be reserved for subjects who require rapid weight loss for a particular purpose, like surgery. the load regain when the diet is stopped is usually rapid, and it’s better to require a more sustainable approach than to use a way that can’t be sustained.

 

 

Overview of therapy for obesity in adults

The morbidity and mortality related to being overweight or obese are known to the medical community since the time of Hippocrates over 2500 years ago. Overweight refers to a weight above the “normal” range, with normal defined on the idea of actuarial data. this is often determined by calculating the body mass index (BMI, defined because the weight in kilograms divided by height in meters squared). Overweight is defined as a BMI of 25 to 29.9 kg/m 2 ; obesity is defined as a BMI of ≥30 kg/m 2 . Severe obesity is defined as a BMI ≥40 kg/m 2 (or ≥35 kg/m 2 within the presence of comorbidities).
An overview of therapy for obesity is provided here. Information on specific therapies for obesity and health hazards related to obesity is reviewed intimately elsewhere.

CLINICAL GUIDELINES

— Several guidelines are available for the evaluation and treatment of obesity including:
• The American Gastroenterological Association (AGA) medical position statement and technical review also available on the AGA website
• American College of Physicians
• National Heart Lung and Blood Institute and therefore the North American Association for the Study of Obesity
Some of these approaches are reviewed well separately.
PREVALENCE


Adults —

Obesity could be a chronic disease that’s increasing in prevalence within the us and worldwide. the proportion of usa citizens with a BMI above 25 kg/m 2 or 30 kg/m 2 has been determined in several government surveys, beginning in 1960 the information are collected in two different ways: annual telephone surveys conducted by state Departments of Health unitedly with the Centers for Disease Control and Prevention in Atlanta, GA (the Behavioral Risk Factor closed-circuit television [BRFSS]), and direct measurement of height and weight in field surveys (National Health and Nutrition Examination surveys).
BRFSS data provides a prevalence that’s about two-thirds that of the NHANES surveys this might be because people underreport their weight, over-report their height, or both, during the phonephone surveys. Data would suggest that they are doing a touch of both. When reading the literature on prevalence of overweight within the US, it’s therefore important to spot which method has been used.
Behavioral risk factor (telephone) survey
— The subjective prevalence of obesity (obtained by self-report) within the us increased from a median of 19.8 percent in 2000 to 26.7 percent in 2009
Although the prevalence of obesity varies across states within the US by 2004 all states had over 15 percent obesity. In 2009, just about one state (Colorado) reported over 20 percent obesity while nine states reported quite 30 percent obesity
National health and nutrition examination survey (NHANES) — The measured prevalence of obesity is on top of the phonephone prevalence (35.7 percent versus 26 percent) based upon data collected for NHANES between 2009 and 2010 The NHANES-measured prevalence of obesity among patients with type 2 DM is even higher (54.8 percent measured between 1999 and 2002) The age-adjusted prevalence of sophistication 3 obesity (BMI ≥40), sometimes spoken as severe obesity, was 6.3 percent in 2009 to 2010
Although the prevalence of obesity increased substantially within the period between the 1976 to 1980 and 1999 to 2000 NHANES, it failed to significantly change in women over the ten year period from 1999 to 2008 or in men over the five year period from 2003 to 2008 Compared with 2003 to 2008, there was also no change within the prevalence of obesity in 2009 to 2010 (35.5 and 35.8 percent among adult men and girls, respectively
Canada
— In Canada, fewer than 10 percent of individuals were obese altogether nine provinces in 1985, but by 1990 only three provinces had fewer than 10 percent obese people, and by 1994 no provinces were still during this low percentage category and five had obesity rates between 15 and 19 percent ]. Between 2007 and 2009, over 27 percent of men and 23 percent of girls were obese, a gradual and distressing increase These data and people from other countries are indicative of a serious international epidemic.

Worldwide

— Mean body mass index is increasing worldwide Despite the wide selection, all data suggest that the majority populations have increased the proportion who are overweight over the past 20 years. Reported prevalence rates of obesity include 11 percent of men and 10 percent of ladies in Belgium (2002 to 2004), 23 percent of men and girls within the UK (2009), 24 percent of men and 34 percent of girls in Mexico (2006), 9 percent of men and 27 percent of ladies in Republic of South Africa (2003), and eight percent of men and 13 percent of ladies in Pakistan (1994
There appears to be a changing perception of obesity. This was illustrated in an exceedingly population survey study during which fewer overweight and obese individuals defined themselves as overweight in 2007 compared to 1999, despite a big increase within the prevalence of obesity
Children and adolescents — The prevalence of obesity has also increased among children and adolescents within the u. s. .)

LIFETIME RISK

— The lifetime risk of developing overweight within the us is critical. Using the info from the Framingham Heart Study the calculated four-year risk of becoming overweight (BMI >25 kg/m 2 ) for men and girls at ages 30, 40, and 50 who had a standard BMI at each age was 14 to 19 percent in women and 26 to 30 percent in men. The four-year risk for developing a BMI >30 kg/m 2 if BMI was normal at baseline was 5 to 7 percent for ladies and seven to 9 percent for men. Over the longer 30-year interval, the risks were similar in men and girls, and varied somewhat with age, being lower if you were under 50 years old. The 30-year risk was one in two (50 percent) of developing overweight (BMI >25 kg/m 2 ), was one in four (25 percent) of developing a BMI >30 kg/m 2 , and 1 in 10 (10 percent) of developing a BMI >35 kg/m 2 and also the long-term (10 to 30 year) risk of becoming overweight


IMPORTANCE OF WEIGHT LOSS

— The medical rationale for weight loss in obese subjects is that obesity is related to a big increase in mortality) and plenty of health risks including type 2 diabetes, hypertension, dyslipidemia, and coronary cardiovascular disease. These risks are reviewed very well separately.
Benefits of weight loss
— insurance reports were the primary to suggest that reducing weight lowers morbidity and mortality. This notion has subsequently been supported in other studies that are reviewed thoroughly separately.
In spite of the known risks of obesity and therefore the health benefits of weight loss, clinicians are diagnosing obesity and recommending therapy in mere a minority of patients..

Maintenance of weight loss

— Achieving and maintaining weight loss is created difficult by the reduction in energy expenditure that’s induced by weight loss. In one study, as an example, maintenance of weight at 10 percent below the baseline weight in obese subjects was related to an 8 kcal/kg decrease in energy expenditure
Recidivism, which is regaining of lost weight, could be a common problem in treating obesity. Some reports suggest that subjects who change state during any treatment program might not maintain the load loss variety of strategies to assist maintain weight loss are reviewed separately..
Characteristics of these who are likely to succeed include a weight loss of over 2 kg in four weeks, frequent and regular attendance at a weight loss program, and therefore the subject’s belief that his or her weight is controlled. Behavioral interventions can also help individuals maintain their weight loss..
Exercise consistently stands out as a crucial consider maintaining weight loss after any weight reduction.
Risks of weight loss — Some studies have suggested that weight loss is also related to an increased risk of death However, these studies couldn’t distinguish intentional from unintentional weight loss. When intentional weight loss was distinguished from unintentional weight loss], intentional weight reduced mortality, whereas unintentional weight was related to increased risk of mortality.
Weight loss may increase the likelihood of cholelithiasis because the flux of cholesterol through the biliary system increases. Diets with moderate amounts of fat that trigger gallbladder contraction may reduce this risk. Similarly, therapy with a steroid (eg, ursodeoxycholic acid ) is also advisable in selected subjects, like those that are losing weight rapidly (>1 to 1.5 kg/week).
APPROACH TO THERAPY — over two-thirds of adults within the us are either trying to change state or to take care of their weight However, only 20 percent are both eating fewer calories and interesting in a minimum of 150 minutes of physical activity during leisure weekly. Thus, clinicians can play a crucial role in educating people regarding the necessity for and therefore the optimal strategies for losing weight. For initial weight loss, treatment should be geared toward decreasing food intake and, when possible, increasing energy expenditure. the previous could also be accomplished by dieting, with or without the addition of anti-obesity drugs.
All treatments of obesity entail some risk. Several groups including the Institute of drugs, The National Heart, Lung and Blood Institute together with the North American Association for the Study of Obesity, have provided guidelines to assist in making risk-benefit evaluations and choosing therapy The initial approach to the treatment of overweight or obese subjects must consider the subsequent questions:
• What are the risks of treatment?
• Is treatment appropriate?
• What is that the most appropriate treatment regimen

What are the chances of treatment? — Treatments for obesity are often divided in line with the risk of side effects. Most of the currently available drugs have minor side effects that diminish with treatment; however, some serious side effects are identified that ought to preclude short-term use in subjects who wish to lose small amounts of weight (the majority of overweight people). Even with potentially dangerous drugs, chronic treatment could also be needed when the magnitude of the obesity carries larger risks, eg, a BMI above 30 kg/m 2 , or between 27 and 30 kg/m 2 with complicating factors like diabetes or hypertension
Is treatment appropriate? — The goal of therapy is to forestall the complications of obesity noted above. Both overall fatness and central adiposity should be assessed. The BMI is that the most practical thanks to evaluate the degree of excess weight and therefore the waist circumference is that the most practical measure of central adiposity. BMI is calculated as follows:
BMI = weight (in kg) ÷ square of stature (height squared, in meters)
The BMI is estimated from a table or a calculator BMI is correlated with body fat and is comparatively unaffected by height. Overweight and obesity are defined as a BMI between 25 and 29.9 kg/m 2 and ≥30 kg/m 2 , respectively.
Waist circumference is measured with a metal or plastic, nondistensible measuring device, placed round the abdomen at the umbilicus parallel to the ground with the patient standing
When estimating the cardiovascular risk related to obesity from the BMI, both regional fat distribution and comorbid conditions should be taken under consideration..
• A BMI of 20 to 25 kg/m 2 is related to little or no increased risk unless visceral fat is high, or the topic has gained over 10 kg since age 18 years.
• Subjects with a BMI of 25 to 30 kg/m 2 could also be described as having low risk, while those with a BMI of 30 to 35 kg/m 2 are at moderate risk.
• Subjects with a BMI of 35 to 40 kg/m 2 are at high risk, and people with a BMI above 40 kg/m 2 are at very high risk from their obesity.
Central adiposity
— At any given level of BMI, the chance to health is increased by more abdominal fat, dyslipidemia, hypertension, age but 40 years, male sex, and a robust case history of diabetes, hypertension, or cardiopathy. With these measures, the presence of the Metabolic Syndrome are often diagnosed. Its presence suggests increased risk for diabetes and cardiovascular disease.
Subjects within the highest risk categories should receive the foremost aggressive treatment.
Some subjects may need to melt off, whether or not they’re not “overweight.” For this group, exercise is that the first recommendation. additionally, psychotherapy techniques and a diet is also helpful.

What is the foremost appropriate treatment?

— Treatments for obesity either decrease energy intake or increase energy expenditure. those who decrease energy intake have a greater potential for causing weight loss than those who increase energy expenditure through exercise.
All of our nutrient energy comes from food and beverages; thus, we will potentially reduce nutrient intake to zero (starvation). In contrast, energy expenditure encompasses a minimum level related to the energy required to keep up vital sign, repair tissues, and maintain function of the guts and other organs. Simply staying in bed reduces energy expenditure to approximately 0.8 kcal/min (1150 kcal/day) for a normal-weight adult. High levels of physical activity can increase energy expenditure four- to eightfold.
Thus, for initial weight loss, treatment should be geared toward decreasing food intake and, when possible, increasing energy expenditure. the previous could also be accomplished by dieting, with or without the addition of anti-obesity drugs.

Behavior modification

— psychotherapy or behavior modification is one cornerstone within the treatment for obesity. These concepts are usually included in programs conducted by psychologists or other trained personnel moreover as many self-help groups

Dietary therapy — Approximately 22 to 25 kcal/kg is required to keep up one kilogram of weight in an exceedingly normal adult. Thus, the expected or calculated energy expenditure for a girl weighing 100 kg is approximately 2200 to 2500 kcal/day. The variability of ± 20 percent could make energy needs as high as 2620 to 3000 kcal/day and as low as 1860 to 2000 kcal/day.
No adult who has been studied in an exceedingly metabolic chamber has needed fewer than 1000 kcal/day for weight maintenance. Thus, even subjects who claim to be “metabolically resistant” to weight loss should turn if they suits a diet of 800 to 1200 kcal/day. If subjects claim to eat but 1200 kcal/day and yet don’t thin one can conclude they’re recording intake erroneously and suggest that they reduce by half what they claim to eat. More severe caloric restriction may well be expected to induce weight loss more quickly, but a comparison with 400 versus 800 kcal/day diet formulas showed no difference in weight loss. We thus recommend diets with >800 kcal/day.
The selection of a diet depends upon the subjects’ preferences. like any treatment recommendation, the patient’s expectations should be assessed. Many patients and a few clinicians have unrealistic expectations of the speed that individuals can thin. A loss of 5 percent or more by six months is realistic, but over that’s often seen. If weight loss is related to improvement in associated risk factors and is maintained, then therapy has been “successful” with today’s treatment programs.
If weight loss is a smaller amount than 5 percent within the first six months, something else should be tried. One option would be to use portion-controlled foods like frozen dinners or lunch entrees, and shakes or food bars that have an outlined number of calories Weight loss of quite 5 percent of initial weight is satisfactory; but one-half of subjects will lose 10 percent or more of initial weight before reaching a plateau.
The addition of dietary counseling may facilitate weight loss, particularly during the primary year.)


Exercise

— Increasing energy expenditure through physical activity has particular attractiveness in efforts at long-term maintenance of a lower weight.
Drug therapy
— Drug therapy could also be a helpful component of the treatment regimen for obese subjects; it is considered for those with a BMI greater than 30 kg/m 2 , or a BMI of 27 to 29.9 kg/m 2 if they need comorbid conditions]. The role of drug therapy has been questioned thanks to concerns about efficacy, the potential for abuse, and side effects.)


Liposuction

— Removal of fat by aspiration after injection of physiologic saline has been accustomed remove and contour subcutaneous fat. While this will end in a big reduction in fat mass and weight, it doesn’t appear to boost insulin sensitivity or risk factors for coronary heart condition. This was illustrated in an exceedingly study of 15 obese women (eight with normal glucose tolerance and 7 with type 2 diabetes) who underwent metabolic evaluation before and 10 to 12 weeks after large-volume abdominal liposuction with the subsequent results]:
• Liposuction decreased the amount of subcutaneous abdominal fatty tissue by 44 percent (9 kg) within the women with normal glucose tolerance and 28 (10.5 kg) percent in those with diabetes.
• Although waist circumference and plasma leptin concentrations were significantly decreased, no improvements in insulin sensitivity of muscle, liver, or animal tissue were seen in either group (assessed by the stimulation of glucose disposal, the suppression of glucose production, and therefore the suppression of lipolysis, using euglycemic hyperinsulinemic clamps and isotope-tracer infusions).
• Liposuction failed to alter plasma concentrations of C-reactive protein, interleukin-6, tumor necrosis factor alpha, or adiponectin and there have been no significant improvements in other risk factors for coronary heart condition including pressure, plasma glucose, lipid, or insulin concentrations..)
Thus, removal of enormous volumes of subcutaneous abdominal fat with liposuction doesn’t improve insulin sensitivity or risk factors for coronary cardiopathy in obese women with or without type 2 diabetes, suggesting that the negative energy balance induced by decreased nutritional intake and/or removal of visceral fat are necessary for achieving the metabolic benefits of weight loss.

Surgery

— Several surgical approaches (collectively remarked as “bariatric surgery”) are accustomed treat severe obesity that has not skillful the above approaches. Indications for the surgical management of morbid obesity were outlined by the National Institutes of Health (NIH) Consensus Development Panel in 1991 and still represent generally-accepted guidelines. Potentially eligible patients should: • Be well-informed and motivated • Have a BMI ≥40 kg/m 2 • Have acceptable risk for surgery • Have failed previous non-surgical weight loss The NIH also suggested that adults with a BMI ≥35 kg/m 2 who have serious comorbidities like severe diabetes, sleep disorder, or joint disease can also be candidates. In a meta-analysis, a majority of patients undergoing bariatric surgery for obesity experienced complete resolution or improvement in diabetes, hypertension, hyperlipidemia, and obstructive sleep disorder In addition, a randomized, trial found that laparoscopic adjustable gastric banding was significantly more practical than medical management at two years follow-up in patients with mild to moderate obesity (BMI 30 to 35 kg/m 2 ) This topic is discussed thoroughly elsewhere. ( Complementary therapies — variety of complementary therapies, specifically, ephedra and other dietary supplements, are used for weight loss. These are described well elsewhere. Acupuncture has also been studied for the treatment of obesity. While most studies are uncontrolled trials, results from some, but not all controlled trials have shown modest advantage of acupuncture for weight loss However, the bulk of those controlled trials are small, of short duration, and don’t include adequate placebo controls. INFORMATION FOR PATIENTS — UpToDate offers two sorts of patient education materials, “The Basics” and “Beyond the fundamentals.” the fundamentals patient education pieces are written in plain language, at the 5 th to six th grade reading level, and that they answer the four or five key questions a patient might need a few given condition. These articles are best for patients who desire a general overview and preferring short, easy-to-read materials. Beyond the fundamentals patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the ten th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to the present topic. We encourage you to print or e-mail these topics to your patients. (You can even locate patient education articles on a spread of subjects by searching on “patient info” and also the keyword(s) of interest.) • Basics topics • Beyond the fundamentals topics SUMMARY and proposals • The medical rationale for weight loss in obese subjects is that obesity is related to a big increase in mortality ) and lots of health risks including type 2 diabetes, hypertension, dyslipidemia, and coronary cardiopathy. • Selection of treatment for overweight subjects is predicated upon an initial risk assessment. • All patients who are overweight (BMI ≥25 kg/m 2 ) or obese (BMI ≥30 kg/m 2 ) should receive counseling on diet, lifestyle, and goals for weight management. for people with a BMI >30 kg/m2 or a BMI of 27 to 29.9 kg/m2 with comorbidities, who have did not achieve weight loss goals through diet and exercise alone, we advise pharmacologic therapy be added to diet and exercise Detailed recommendations for pharmacotherapy are discussed separately. .) • For patients with BMI ≥40 kg/m 2 who have did not slenderize with diet, exercise, and drug therapy, we recommend bariatric surgery Individuals with BMI >35 kg/m2 with obesity-related comorbidities (hypertension, impaired glucose tolerance, DM, dyslipidemia, sleep apnea) who have failed diet, exercise, and drug therapy are potential surgical candidates, assuming that the anticipated benefits outweigh the prices, risks, and side effects of the procedure.