Weight Management Therapies

Effective weight control involves multiple techniques and strategies including dietary therapy, physical activity, behavior therapy, pharmacotherapy, and surgery as well as combinations of these strategies. Relevant treatment strategies can also be used to foster long-term weight control and prevention of weight gain.

Some strategies such as modifying dietary intake and physical activity can also impact on obesity-related comorbidities or risk factors.

Increased physical activity is not only important for weight loss and weight loss maintenance but also impacts on other comorbidities and risk factors such as high blood pressure, and high blood cholesterol levels.  Reducing body weight in overweight and obese patients not only helps reduce the risk of these comorbidities from developing but also helps in their management.  Weight management techniques need to take into account the needs of individual patients so they should be culturally sensitive and incorporate the patient’s perspectives and characteristics. Treatment of overweight and obesity is to be taken seriously since it involves treating an individual’s disease over the long term as well as making modifications to a way of life for entire families.

Dietary Therapy

In the majority of overweight and obese patients, adjustment of the diet will be required to reduce caloric intake. Dietary therapy includes instructing patients in the modification of their diets to achieve a decrease in caloric intake.

A diet that is individually planned to help create a deficit of 500 to 1,000 kcal/day should be an integral part of any program aimed at achieving a weight loss of 1 to 2 pounds per week. A key element of the current recommendation is the use of a moderate reduction in caloric intake, which is designed to achieve a slow, but progressive, weight loss. Ideally, caloric intake should be reduced only to the level that is required to maintain weight at a desired level. If this level of caloric intake is achieved, excess weight will gradually decrease. In practice, somewhat greater caloric deficits are used in the period of active weight loss, but diets with a very low-calorie content are to be avoided. Finally, the composition of the diet should be modified to minimize other cardiovascular risk factors.

The centerpiece of dietary therapy for weight loss in overweight or obese patients is a low calorie diet (LCD).  This diet is different from a very low calorie diet (VLCD) (less than 800 kcal/day). In general, diets containing 1,000 to 1,200 kcal/day should be selected for most women; a diet between 1,200 kcal/day and 1,600 kcal/day should be chosen for men and may be appropriate for women who weigh 165 pounds or more, or who exercise regularly.

If the patient can stick with the 1,600 kcal/day diet but does not lose weight you may want to try the 1,200 kcal/day diet. If a patient on either diet is hungry, you may want to increase the calories by 100 to 200 per day.

VLCDs should not be used routinely for weight loss therapy because they require special monitoring and supplementation.

VLCDs are used only in very limited circumstances by specialized practitioners experienced in their use. Moreover, clinical trials show that LCDs are as effective as VLCDs in producing weight loss after 1 year.

Successful weight reduction by LCDs is more likely to occur when consideration is given to a patient’s food preferences in tailoring a particular diet. Care should be taken to ensure that all of the recommended dietary allowances are met; this may require the use of a dietary or vitamin supplement.

Dietary education is necessary to assist in the adjustment to a LCD. Educational efforts should pay particular attention to the following topics:

1. Energy value of different foods.
2. Food composition—fats, carbohydrates (including dietary fiber), and proteins.
3. Evaluation of nutrition labels to determine caloric content and food composition.
4. New habits of purchasing—give preference to low-calorie foods.
5. Food preparation—avoid adding high-calorie ingredients during cooking (e.g., fats and oils).
6. Avoiding overconsumption of high-calorie foods (both high-fat and high-carbohydrate foods).
7. Adequate water intake.
8. Reduction of portion sizes.
9. Limiting alcohol consumption.

Physical Activity

Physical activity should be an integral part of weight loss therapy and weight maintenance.  Initially, moderate levels of physical activity for 30 to 45 minutes, 3 to 5 days per week, should be encouraged.  An increase in physical activity is an important component of weight loss therapy, although it will not lead to a substantially greater weight loss than diet alone over 6 months.

Most weight loss occurs because of decreased caloric intake. Sustained physical activity is most helpful in the prevention of weight regain.

In addition, physical activity is beneficial for reducing risks for cardiovascular disease and type 2 diabetes, beyond that produced by weight reduction alone. Many people live sedentary lives, have little training or skills in physical activity, and are difficult to motivate toward increasing their activity. For these reasons, starting a physical activity regimen may require supervision for some people. The need to avoid injury during physical activity is a high priority.

Extremely obese persons may need to start with simple exercises that can be intensified gradually. The practitioner must decide whether exercise testing for cardiopulmonary disease is needed before embarking on a new physical activity regimen.  This decision should be based on a patient’s age, symptoms, and concomitant risk factors.

For most obese patients, physical activity should be initiated slowly, and the intensity should be increased gradually. Initial activities may be increasing small tasks of daily living such as taking the stairs or walking or swimming at a slow pace. With time, depending on progress, the amount of weight lost, and functional capacity, the patient may engage in more strenuous activities. Some of these include fitness walking, cycling, rowing, cross-country skiing, aerobic dancing, and jumping rope. Jogging provides a high-intensity aerobic exercise, but it can lead to orthopedic injury. If jogging is desired, the patient’s ability to do this must first be assessed. The availability of a safe environment for the jogger is also a necessity. Competitive sports, such as tennis and volleyball, can provide an enjoyable form of physical activity for many, but again, care must be taken to avoid injury, especially in older people.

A moderate amount of physical activity can be achieved in a variety of ways. People can select activities that they enjoy and that fit into their daily lives. Because amounts of activity are functions of duration, intensity, and frequency, the same amounts of activity can be obtained in longer sessions of moderately intense activities (such as brisk walking) as in shorter sessions of more strenuous activities (such as running).

A regimen of daily walking is an attractive form of physical activity for many people, particularly those who are overweight or obese. The patient can start by walking 10 minutes, 3 days a week, and can build to 30 to 45 minutes of more intense walking at least 3 days a week and increase to most, if not all, days.

With this regimen, an additional 100 to 200 kcal/day of physical activity can be expended. Caloric expenditure will vary depending on the individual’s body weight and the intensity of the activity.

This regimen can be adapted to other forms of physical activity, but walking is particularly attractive because of its safety and accessibility.

With time, a larger weekly volume of physical activity can be performed that would normally cause a greater weight loss if it were not compensated by a higher caloric intake.

Reducing sedentary time, i.e., time spent watching television or playing video games, is another approach to increasing activity.  Patients should be encouraged to build physical activities into each day. Examples include leaving public transportation one stop before the usual one, parking farther than usual from work or shopping, and walking up stairs instead of taking elevators or escalators.

New forms of physical activity should be suggested (e.g., gardening, walking a dog daily, or new athletic activities). Engaging in physical activity can be facilitated by identifying a safe area to perform the activity (e.g., community parks, gyms, pools, and health clubs). However, when these sites are not available, an area of the home can be identified and perhaps outfitted with equipment such as a stationary bicycle or a treadmill. Health care professionals should encourage patients to plan and schedule physical activity 1 week in advance, budget the time necessary to do it, and document their physical activity by keeping a diary and recording the duration and intensity of exercise.

The following are examples of activities at different levels of intensity.

A moderate amount of physical activity is roughly equivalent to physical activity that uses approximately 150 calories of energy per day, or 1,000 calories per week.

Very light activity would include increased standing activities, room painting, pushing a wheelchair, ironing, cooking, and playing a musical instrument.

Light activity would include slow walking (24 min/mile), garage work, carpentry, house cleaning, child care, golf, sailing, and recreational table tennis.

Moderate activity would include walking a 15-minute mile, weeding and hoeing a garden, carrying a load, cycling, skiing, tennis, and dancing.

High activity would include jogging a mile in 10 minutes, walking with a load uphill, tree felling, heavy manual digging, basketball, climbing, and soccer.

Other key activities would include flexibility exercises to attain full range of joint motion, strength or resistance exercises, and aerobic conditioning.

Exercise Considerations

Very large people face special challenges in trying to be active. They may not be able to bend or move in the same way that other people can. It may be hard to find clothes and equipment for exercising. They may also feel self-conscious being physically active around other people.

Walking

If the patient is not normally active, they should start slowly. Begin by walking 5 minutes a day for the first week. Walk 8 minutes the next week. Stay at 8–minute walks until they feel comfortable. Then increase the walks to 11 minutes. Slowly lengthen each walk by 3 minutes—or walk faster.

Tips for walking:

• The patient should wear comfortable walking shoes with a lot of support. If they walk often, they may need to buy new shoes every 6 to 8 months.
• Wear garments that prevent inner thigh chafing, such as tights or spandex shorts.
• Make walking fun. Walk with a friend or pet. Walk in places they enjoy, like a park or shopping mall.

Dancing

The patient can dance in a health club, in a nightclub, or at home. To dance at home, just have them move their body to some lively music.  Dancing on their feet is a good weight-bearing activity, however, if they can’t stand for very long, encourage them to dance while seated.

Water Workouts

The patient does not need to know how to swim to work out in water—they can do shallow-water or deep-water exercises without swimming.

For shallow-water exercise, the water level should be between their waist and their chest. If the water is too shallow, it will be hard to move their arms underwater. If the water is deeper than chest height, it will be hard to keep their feet touching the pool bottom.

For deep-water exercise, most of the patient’s body is underwater. This means that the whole body will get a good workout. For safety and comfort, they should wear a foam belt or life jacket.

Weight Training

The patient does not need benches or bars to begin weight training at home. They can use a pair of hand weights or even two soup cans.  Make sure they know the correct posture and that their movements are slow and controlled.

Before the patient buys a home gym, they should check its weight rating (the number of pounds it can support) to make sure it is safe for their size.

Bicycling

Bicycling can be done indoors on a stationary bike, or outdoors on a road bike. The patient may benefit from using a recumbent bike because the seat on a recumbent bike is usually wider than the seat on an upright bike. For biking outdoors, they may want to try a mountain bike. These bikes have wider tires and are generally heavy duty.

As with the home gym, the patient should make sure that the bike that they buy has a weight rating at least as high as their own weight.

Lifestyle Activities

Lifestyle physical activities do not have to be planned. The patient can make small changes to make their day more physically active and improve their health. For example,

• Take 2- to 3-minute walking breaks at work a few times a day.
• Put away the TV remote control—get up to change the channel.
• March in place during TV commercials.
• Sit in a rocking chair and push off the floor with their feet.
• Take the stairs instead of the elevator.

Exercise Safety Tips

The patient should be reminded to stop their activity immediately if they experience any of the following:

• have pain, tightness, or pressure in their chest or left neck, shoulder, or arm
• have shortness of breath
• feel dizzy or sick
• break out in a cold sweat
• have muscle cramps
• feel pain in their joints, feet, ankles, or legs.

Behavior Therapy

Behavioral strategies to reinforce changes in diet and physical activity can produce a weight loss in obese adults in the range of 10 percent of baseline weight over 4 months to 1 year. Unless a patient acquires a new set of eating and physical activity habits, long-term weight reduction is unlikely to succeed. The acquisition of new habits is particularly important for long-term weight maintenance at a lower weight. Most patients return to baseline weights in the absence of continued intervention. Thus, healthcare professionals must become familiar with techniques for modifying life habits of overweight or obese patients.

The goal of behavior therapy is to alter the eating and activity habits of an obese patient. Techniques for behavior therapy have been developed to assist patients in modifying their life habits.

Read Also

Behavior therapies provide methods for overcoming barriers to compliance with dietary therapy and/or increased physical activity, and are thus important components of weight loss therapy. Most weight loss programs incorporating behavioral strategies do so as a package that includes education about nutrition and physical activity. However, this standard "package" of management should not ignore the need for individualizing behavioral strategies.

No single method or combination of behavioral methods proved to be clearly superior. Thus, various strategies can be used by the practitioner to modify patient behavior. The aim is to change eating and physical activity behaviors over the long term. Such change can be achieved either on an individual basis or in group settings. Group therapy has the advantage of lower cost. Specific behavioral strategies include the following:

Self-monitoring of both eating habits and physical activity—Objectifying one's own behavior through observation and recording is a key step in behavior therapy. Patients should be taught to record the amount and types of food they eat, the caloric values, and nutrient composition. Keeping a record of the frequency, intensity, and type of physical activity likewise will add insight to personal behavior. Extending records to time, place, and feelings related to eating and physical activity will help to bring previously unrecognized behavior to light.

Stress management — Stress can trigger dysfunctional eating patterns, and stress management can defuse situations leading to overeating. Coping strategies, meditation, and relaxation techniques all have been successfully employed to reduce stress.

Stimulus control — Identifying stimuli that may encourage incidental eating enables individuals to limit their exposure to high-risk situations. Examples of stimulus control strategies include learning to shop carefully for healthy foods, keeping high-calorie foods out of the house, limiting the times and places of eating, and consciously avoiding situations in which overeating occurs.

Problem solving — This term refers to the self-corrections of problem areas related to eating and physical activity. Approaches to problem solving include identifying weight-related problems, generating or brainstorming possible solutions and choosing one, planning and implementing the healthier alternative, and evaluating the outcome of possible changes in behavior.  Patients should be encouraged to reevaluate setbacks in behavior and to ask "What did I learn from this attempt?" rather than punishing themselves.

Contingency management — Behavior can be changed by use of rewards for specific actions, such as increasing time spent walking or reducing consumption of specific foods. Verbal as well as tangible rewards can be useful, particularly for adults. Rewards can come from either the professional team or from the patients themselves. For example, self-rewards can be monetary or social and should be encouraged.

Cognitive restructuring — Unrealistic goals and inaccurate beliefs about weight loss and body image need to be modified to help change self-defeating thoughts and feelings that undermine weight loss efforts. Rational responses designed to replace negative thoughts are encouraged.  For example, the thought, "I blew my diet this morning by eating that doughnut; I may as well eat what I like for the rest of the day," could be replaced by a more adaptive thought, such as, "Well, I ate the doughnut this morning, but I can still eat in a healthy manner at lunch and dinner."

Social support — A strong system of social support can facilitate weight reduction. Family members, friends, or colleagues can assist an individual in maintaining motivation and providing positive reinforcement. Some patients may benefit by entering a weight reduction support group. Overweight patients should be asked about (possibly) overweight children and family weight control strategies. Parents and children should work together to engage in and maintain healthy dietary and physical activity habits.

Combined Therapy

To achieve the greatest likelihood of success from weight loss therapy, the combination of dietary therapy with an LCD, increased physical activity, and behavior therapy will be required. Inclusion of behavior therapy and increased physical activity in a weight loss regimen will provide the best opportunity for weight loss, and hopefully for long-term weight control. In order to achieve weight loss, such a regimen should be maintained for at least 6 months before considering pharmacotherapy

Pharmacotherapy

Prescription weight-loss medications should be used only by patients who are at increased medical risk because of their weight. They should not be used for “cosmetic” weight loss. Prescription weight-loss drugs are approved only for those with a body mass index (BMI) of 30 and above, or 27 and above if they have obesity-related conditions, such as high blood pressure, dyslipidemia, or type 2 diabetes.

Although most side effects of prescription medications for obesity are mild, serious complications have been reported. Also, there are few studies lasting more than 2 years evaluating the safety or effectiveness of weight-loss medications. Weight-loss medications should always be combined with a program of healthy eating and regular physical activity.

Appetite Suppressants.

Most available weight-loss medications approved by the Food and Drug Administration (FDA) are appetite-suppressant medications. Appetite-suppressant medications promote weight loss by decreasing appetite or increasing the feeling of being full. These medications make you feel less hungry by increasing one or more brain chemicals that affect mood and appetite. Phentermine and sibutramine are the most commonly prescribed appetite-suppressants in the U.S.

Lipase inhibitors.

One drug works in a different way. Orlistat works by reducing the body’s ability to absorb dietary fat by about one third. It does this by blocking the enzyme lipase, which is responsible for breaking down dietary fat. When fat is not broken down, the body cannot absorb it, so fewer calories are taken in.

Other medications (not FDA-approved for the treatment of obesity).

·         Drugs to treat depression. Some antidepressant medications have been studied as appetite-suppressant medications. While these medications are FDA-approved for the treatment of depression, their use in weight loss is an “off-label” use (see box). Studies of these medications generally have found that patients lose modest amounts of weight for up to 6 months, and tend to regain weight while they are still on the drug. One exception is bupropion. In one study, patients taking buproprion maintained weight loss for up to 1 year.

·         Drugs to treat seizures. Two medications used to treat seizures, topiramate and zonisamide, have been shown to cause weight loss. Whether these drugs will be useful in treating obesity is being studied.

·         Drugs to treat diabetes. The diabetes medication metformin may promote small amounts of weight loss in people with obesity and type 2 diabetes. How this medication promotes weight loss is not clear, although research has shown reduced hunger and food intake in people taking the drug.

·         Drug combinations. The combined drug treatment using fenfluramine and phentermine (“fen/phen”) is no longer available due to the withdrawal of fenfluramine from the market after some patients experienced serious heart and lung disorders. Little information is available about the safety or effectiveness of other drug combinations for weight loss, including fluoxetine/phentermine, phendimetrazine/phentermine, orlistat/sibutramine, herbal combinations, or others.

·         Drugs in development. Many medications are being tested as potential treatments for obesity. Two are being studied with patients in clinical trials. Rimonabant affects brain chemicals and ciliary neurotrophic factor affects hormones to control appetite. Currently, these medications are only available in clinical trials. Clinical trials are research studies with human volunteers so that specific health questions can be answered.

Approved for long-term use
Generic Name	Trade Name(s)	Drug Type	FDA Approval Date
orlistat	Xenical	lipase inhibitor	1999
sibutramine	Meridia	appetite suppressant	1997

Approved for short-term use
Generic Name	Trade Name(s)	Drug Type	FDA Approval Date
diethylpropion	Tenuate, Tenuate dospan	appetite suppresant	1959
phendimetrazine	Bontril, Plegine, Prelu-2, X-Trozine, Adipost	appetite suppresant	1982
phentermine	Adipex-P, Fastin, Ionamin, Oby-trim, Pro-Fast, Zantryl	appetite suppresant	1959

Benefits

People respond differently to weight-loss medications, and some people experience more weight loss than others. Weight-loss medications lead to an average weight loss of 5 to 22 pounds more than what you might lose with non-drug obesity treatments. Some patients using medication lose more than 10 percent of their starting body weight. Maximum weight loss usually occurs within 6 months of starting medication treatment. Weight then tends to level off or increase during the remainder of treatment.

Over the short term, weight loss in individuals who are obese may reduce a number of health risks. Studies have found that weight loss with some medications improves blood pressure, blood cholesterol, triglycerides (fats), and insulin resistance (the body’s inability to use blood sugar). New research suggests that long-term use of weight-loss medications may help individuals keep off the weight they have lost. However, more studies are needed to determine the long-term effects of weight-loss medications on weight and health.

Potential Risks

When considering long-term weight-loss medication treatment for obesity, you should consider the following areas of concern and potential risks.

·         Potential for abuse or dependence. Currently, all prescription medications to treat obesity except orlistat are controlled substances, meaning doctors need to follow certain restrictions when prescribing them. Although abuse and dependence are not common with non-amphetamine appetite-suppressant medications, doctors should be cautious when they prescribe these medications for patients with a history of alcohol or other drug abuse.

·         Development of tolerance. Most studies of weight-loss medications show that a patient’s weight tends to level off after 6 months while still on medication. Although some patients and doctors may be concerned that this shows tolerance to the medications, the leveling off may mean that the medication has reached its limit of effectiveness. Based on the currently available studies, it is not clear if weight gain with continuing treatment is due to drug tolerance. It is clear, however, that weight gain would be much faster if the patient stopped taking the drug.

·         Reluctance to view obesity as a chronic disease. Obesity often is viewed as the result of a lack of willpower, weakness, or a lifestyle “choice”—the choice to overeat and underexercise. Such social views on obesity should not prevent patients from seeking medical treatment to prevent health risks that can cause serious illness and death. Weight-loss medications, however, are not “magic bullets” or a one-shot fix for this chronic disease. They should be combined with a healthy eating plan and increased physical activity.

·         Side effects. Because weight-loss medications are used to treat a condition that affects millions of people, many of whom are basically healthy, the possibility that side effects may outweigh benefits is of great concern. Most side effects of these medications are mild and usually improve with continued treatment. Rarely, serious and even fatal outcomes have been reported. Side effects of medications are explained below.

Orlistat. Some side effects of orlistat include cramping, intestinal discomfort, passing gas, diarrhea, and leakage of oily stool. These side effects are generally mild and temporary, but may be worsened by eating foods that are high in fat. Also, because orlistat reduces the absorption of some vitamins, patients should take a multivitamin at least 2 hours before or after taking orlistat.

Sibutramine. The main side effects of sibutramine are increases in blood pressure and heart rate, which are usually small but may be of concern in some patients. Other side effects include headache, dry mouth, constipation, and insomnia. People with poorly controlled high blood pressure, heart disease, irregular heartbeat, or history of stroke should not take sibutramine, and all patients taking the medication should have their blood pressure monitored on a regular basis.

Other appetite suppressants. Phentermine, phendimetrazine, and diethylpropion may cause symptoms of sleeplessness, nervousness, and euphoria (feeling of well-being). People with heart disease, high blood pressure, an overactive thyroid gland, or glaucoma should not use these drugs.

Two appetite-suppressant medications, fenfluramine and dexfenfluramine, were withdrawn from the market in 1997. These drugs, used alone and in combination with phentermine (“fen/phen”) were linked to the development of valvular heart disease and primary pulmonary hypertension (PPH), a rare but potentially fatal disorder that affects the blood vessels in the lungs. There have been only a few case reports of PPH in patients taking phentermine alone, but the possibility that phentermine use is associated with PPH cannot be ruled out.