Plasma leptin levels and incidence of heart failure, cardiovascular disease, and total mortality in elderly individuals. Lighten Up randomised controlled trial. The effectiveness of this modality depends on a highly motivated patient and a dedicated counselor who is willing to maintain long-term follow-up. Proteinuria and focal segmental glomerulosclerosis in severely obese adolescents. All are indicated as adjuncts to caloric restriction, increased physical activity, and behavior modification.
Patient Screening, Assessment, and Expectations
Those healthy vegetables added low-cal bulk to the tasty dish. A protein-rich breakfast may help you resist snack attacks throughout the day. The women ate a calorie breakfast that included eggs and a beef sausage patty. The effect of the high-protein breakfast seemed to last into the evening, when the women munched less on fatty, sugary goods than the women who had cereal for breakfast. For a great snack on the run, take a small handful of almonds, peanuts, walnuts, or pecans. Research shows that when people munch on nuts, they automatically eat less at later meals.
Skip the apple juice and the applesauce and opt instead for a crunchy apple. One reason is that raw fruit has more fiber. A Harvard study followed more than , people for a decade or longer. Yogurt, of all the foods that were tracked, was most closely linked to weight loss. Yes, grapefruit really can help you shed pounds, especially if you are at risk for diabetes. Drinking grapefruit juice had the same results.
But grapefruit juice doesn't have any proven "fat-burning" properties -- it may just have helped people feel full. You cannot have grapefruit or grapefruit juice if you are on certain medications, so check the label on all your prescriptions , or ask your pharmacist or doctor.
Load your shopping cart with lots of lean protein, fresh veggies, fruit, and whole grains, says food scientist Joy Dubost, PhD, RD. The most important thing, when it comes to lasting weight loss, is the big picture of what you eat, not specific foods. Delicious foods that help you diet? It sounds too good to be true. So take this list when you go to the supermarket: Beans Inexpensive, filling, and versatile, beans are a great source of protein.
Soup Start a meal with a cup of soup, and you may end up eating less. Dark Chocolate Want to enjoy chocolate between meals? Some of these medications have been used as adjuncts in the medical management of obesity, with variable success.
A meta-analysis of antidepressants and body weight found that fluoxetine was associated with some weight loss, although this effect appeared to be limited to the acute phase of treatment. Bupropion is licensed for use as an antidepressant and for use in smoking cessation.
It is associated with minimal to moderate weight loss in obese patients. Ephedrine and caffeine are second-line options in the medical management of obesity. They both act by increasing energy expenditure, but they are associated with the potential for tachycardia, hypertension, and palpitations.
These medications are associated with greater weight loss when used in combination than when used alone. Currently, the evidence for the efficacy of these 2 drugs in promoting weight loss is inconclusive. Neither substance has an FDA-approved indication for the treatment of obesity. The central cannabinoid system has an increasingly recognized role in appetite and feeding disorders. CB1-receptor antagonists showed great potential for weight management in several human trials.
Adverse effects, which were most prevalent at high doses, included dizziness, depression and suicidal ideation, headaches, nausea, vomiting, and diarrhea. The drug was rejected by the FDA because of side effects of depression and suicidal ideation; in Europe, it was approved but later recalled. A Japanese study found evidence that beverages containing high amounts of catechin, a flavonoid found in green tea, may aid in preventing obesity.
By the 12th week, participants receiving the higher catechin dose had undergone a significantly greater reduction in waist circumference than did patients receiving the lower dose.
The increasing knowledge that has come on the heels of the discovery of leptin by Friedman and colleagues in has spurred a whirlwind of research that has identified several potential pharmaceuticals. However, safety standards for obesity medications are necessarily high. Tolerance for adverse effects is limited; most persons who are obese are fairly healthy in the short term, but the risk for adverse drug effects is enhanced because patients must take antiobesity medications for extended periods possibly for the rest of their lives.
Agents in early phases of investigation that may yet prove useful against obesity include the following:. In addition, various nutraceuticals and herbal products have shown promise. For example, an extract from the African cactus Hoodia gordonii may cause clinically significant appetite suppression.
The diabetes drug pramlintide Symlin , which is a synthetic analogue of the pancreatic hormone amylin, does not have an FDA indication for obesity management. However, this drug is clearly associated with variable weight loss in people with type 1 or 2 diabetes, while improving overall glycemic control.
Higher doses mcg before main meals than those approved for the management of type 2 diabetes mcg before main meals have produced modest weight loss in obese or overweight patients with and without diabetes. Peptide YY is being developed as a nasal inhaler. Ongoing, preliminary phase 1 and 2 trials yielded encouraging results. Leptin is still used in cases of the rare obesity subclass of leptin-deficient obesity and lipodystrophy, but a study of the leptin analogue metreleptin in obese patients with diabetes found that metreleptin did not alter body weight.
Preliminary reports suggest the potential utility of agents that impede dietary carbohydrate absorption. Tagatose is one of the compounds in this class that is undergoing trials. The history of obesity medications is replete with disasters that have taught caution in the use of this group of medicines.
For example, among the initial medications used for obesity management were amphetamine, methamphetamine, and phenmetrazine. These were all withdrawn because of their high potential for abuse. However, fenfluramine was withdrawn in along with D-fenfluramine because of the potential for adverse cardiac, valvular, and pulmonary hypertensive effects in patients taking this drug.
Other former antiobesity medications, and the reasons for their abandonment, include the following:. Rainbow pills a mixture of digitalis and diuretics - Fatal arrhythmias and electrolyte derangements. Some agents that initially showed promise were later demonstrated to be poor prospects in rigorous randomized intervention trials.
These include the following:. One strategy to prevent obesity that is being explored in the dietary industry involves the use of fat substitutes. Olestra Olean has been approved for use as a dietary supplement and additive in various foods, such as potato chips and crackers. Olestra consists of a sucrose polyester backbone with fatty-acid side chains; this structure makes the molecule too large for digestive enzymes of the gut to hydrolyze.
In many trials, olestra had fairly good tolerability, although foods containing it are apparently less tasty than foods cooked in regular fat. The major adverse effects reported were flatulence, bloating, diarrhea, and loose stools. Because of concerns regarding the possible malabsorption of fat-soluble vitamins, the FDA requires all olestra-prepared foods to be supplemented with these vitamins.
Benecol contains stanols, predominantly sitostanol and campestan; Take Control is made up of sterols, primarily beta-sitosterol and campesterol. Weight-loss benefits have not been demonstrated. Surgical therapy for obesity bariatric surgery is the only available therapeutic modality associated with clinically significant and relatively sustained weight loss in subjects with morbid obesity associated with comorbidities.
Evidence shows that well-performed bariatric surgery, in carefully selected patients and with a good multidisciplinary support team, substantially ameliorates the morbidities associated with severe obesity.
Although bariatric surgery is the only therapeutic method associated with significant and rapid weight loss, it is expensive, highly procedure and surgeon specific, and certainly not the solution for the burgeoning obesity epidemic. Patient selection for bariatric procedures must be addressed along the same stringent lines as those discussed earlier for the selection of patients for medical weight-management programs.
Comorbidities that have been reported to be improved, ameliorated, or resolved through bariatric surgery include the following:. Other reports suggest improved quality of life and fertility after bariatric surgery. Although other outcomes are difficult to demonstrate and are awaiting clear documentation, these procedures may substantially reduce macrovascular complications eg, myocardial infarction , stroke, amputations, obesity-related malignancies, and a predisposition to infection, hernias, and varicose veins.
Although most bariatric procedures were initially developed in the setting of laparotomies, they now are increasingly performed laparoscopically, with reduced postoperative morbidity. The laparoscopic approach to bariatric surgery is particularly well developed in Europe. Available data on the effectiveness of many of these procedures are still relatively scant. However, reports and meta-analyses from large numbers of patients on the most commonly performed procedures gastric restriction and gastric bypass lend veracity to the long-term effectiveness of bariatric surgery.
Guidelines from the American Association of Clinical Endocrinologists, The Obesity Society, and the American Society for Metabolic and Bariatric Surgery endorse sleeve gastrectomy as an effective alternative to gastric banding, gastric bypass, and other types of bariatric surgery, saying that the procedure has advanced beyond the investigational stage.
However, the guidelines do not recommend any bariatric procedure as preferable over the others for patients with severe obesity. Flickinger and associates, in an examination of patients who received a Roux-en-Y gastric bypass, recorded a mean weight loss of 51 kg in 18 months, which was then maintained over 36 months of follow-up. Roux-en-Y and other gastric-bypass procedures generally result in more weight loss than do gastric-restriction procedures.
According to a study by Plecka et al, in patients who are morbidly obese, gastric bypass but not restrictive surgery apparently reduces the risk levels for the development of type 2 diabetes and myocardial infarction to those for the general population. However, the mortality risk in these patients nonetheless remains higher than that in the general population. Improvement in glucose control was unrelated to baseline BMI or overall weight loss.
A Norwegian study compared gastric bypass with duodenal switch and determined that duodenal switch surgery was associated with greater weight loss and greater reductions in total and LDL-C levels.
However, duodenal switch surgery was also associated with reductions in concentrations of vitamin A and hydroxyvitamin D, as well as with increased adverse effects. Similarly, a randomized trial from Sweden found greater postoperative weight loss in patients who had duodenal switch surgery than in those who had gastric bypass.
Fasting glucose and HgA1c were also lower at 3 years in the duodenal switch group. A study by Schiavon et al indicated that bariatric surgery can lead to a reduction in the number of antihypertensive drugs required by persons with obesity taking multiple blood pressure agents and in some cases can eliminate the need for any such medications. The investigators found that Emerging data suggest that gastric pacing achieved by using implantable electrodes may have significant weight-loss effects.
This outcome was initially discovered with the use of gastric pacemaker devices for gastroparesis in patients with diabetes. Other adjunctive procedures that may be performed but that have an unclear utility include visceral fat removal, omentectomy, subcutaneous fat panniculectomy, and large-volume subcutaneous fat liposuction.
Klein and colleagues indicated that liposuction in itself has no utility in improving cardiac risk factors among patients with obesity. Some procedures, such as jaw wiring and insertion of a gastric balloon or a gastric wrap, are no longer popular because of their poor results compared with those of newer procedures and because of their high complication rates. Vagotomy has also declined in popularity, as the weight lost is typically regained within a few years.
The mortality rate associated with standard bariatric surgical procedures in an experienced center should not exceed 1. The surgical mortality rate is less than 0. In addition, gastric-specific operations can be associated with persistent vomiting and metabolic alkalosis. These operations are also more commonly associated with weight-loss failure and inadvertent splenectomy than are other surgical methods. Malabsorptive procedures gastric bypass can lead to deficiency of thiamine, iron, vitamin D, and vitamin B Prevalences for adverse events with gastric resection procedures with or without bypass are approximately as follows [ ]:.
Patients who receive bypass procedures are particularly prone to micronutrient deficiency states, especially of calcium, vitamin B, folate, and iron, as well as protein malnutrition. Rare cases of postural hypotension and severe hypoglycemia from nesidioblastosis have been reported. Life-threatening hypoglycemia usually requires partial or total pancreatectomy, while severe postural hypotension that cannot be corrected with fludrocortisone and midodrine requires reversal of the surgery.
The following are among the major specific complications associated with malabsorptive operations:. Failure rates based on weight loss are controversial. The overall failure rates for malabsorptive procedures are relatively low, although the need for reversal of the surgery because of resulting adverse effects appears to be relatively high. Despite the morbidity and mortality risk associated with bariatric surgery, the few reports involving follow-up on patients undergoing these procedures suggest overall improvement in quality of life.
Even more convincing than this finding is that most subjects who undergo these procedures, despite their postoperative complications and difficulties, indicate that they would undergo the procedures again if necessary. Inpatient evaluations of obese patients are important in the immediate postoperative period after antiobesity surgery.
In addition, hospitalization may be required for the management of major complications, such as clinically significant respiratory or cardiac compromise.
Weight-management programs may be based in an outpatient or inpatient setting. No rigorous evidence suggests that inpatient programs are necessarily superior to outpatient programs of similar structure and content, however. Inpatient programs may offer the convenience of easy access to patients and ease of monitoring, but they are not only expensive to run and difficult to reimburse, they also generally cause considerable disruption to the patients' regular routine.
In addition, they offer little guarantee of sustained effect. Because of the sheer prevalence of obesity and the anticipated worsening of the pandemic in the next few decades, prevention is by far the most desirable means to curb the medical and economic consequences of this condition. However, few trials have addressed this issue, and those performed thus far have had mixed results. Given the global proportions of obesity, a concerted approach is needed to address the problem and should involve the development of a massive public health education program aimed at adults and children as a means of changing their eating, activity, and behavioral habits.
Cooperative efforts will also be needed among public health authorities, caterers, the fast food industry, and organizers of sports and outdoor games. Results of some public health education initiatives in Singapore and parts of China that are only now being evaluated suggest, as hoped, that such programs have the potential for reducing the incidence and prevalence of obesity and may also have an impact on the major comorbidities of obesity, such as type 2 diabetes and hypertension.
Until advances in gene therapy permit the alteration of genes that predispose to obesity, such programs are the only preventive options available. In select cases, consultation with a psychiatrist may be indicated. Psychiatric consultation should be sought for patients with psychiatric disorders and personality disorders eg, severe depression, mania, obsessive disorders that may be worsened by attempts at weight loss if not adequately treated and controlled.
As with the management of other chronic medical conditions eg, diabetes mellitus, hypertension, bronchial asthma , long-term success in the management of obesity is contingent on long-standing follow-up with the weight-loss program. Experience obtained from the lifestyle intervention group of patients in the Diabetes Prevention Program and information drawn from the ongoing Diabetes Prevention Program Observation study have borne out the importance of regular follow-up.
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