Obesity medical therapy

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USPSTF Recommendations and Guidelines on Management of Obesity

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Karol Gema Hernandez, M.D. [2]

## Overview

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The main treatment for obesity is to reduce body fat by eating fewer calories and exercising more. A beneficial side effect of exercise is to increase muscle, tendon, and ligament strength, which helps to prevent injury from accidents and vigorous activity. Diet and exercise programs produce an average weight loss of approximately 8% of total body mass (excluding program drop-outs). Not all dieters are satisfied with these results, but a loss of as little as 5% of body mass can create large health benefits.

Much more difficult than reducing body fat is keeping it off. Eighty to ninety-five percent of those who lose 10% or more of their body mass by dieting regain all that weight back within two to five years. The body has systems that maintain its homeostasis at certain set points, including body weight. Therefore, keeping weight off generally requires making exercise and eating right a permanent part of a person's lifestyle. Certain nutrients, such as phenylalanine, are natural appetite suppressants which allow resetting of the body's set point for body weight.

## Clinical Practice Guidelines

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Clinical practice guidelines are available[1][2][3][4]; however, some of the guidelines do not follow recommendations for trustworthiness by the Institute of Medicine[3][4].

### 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society (DO NOT EDIT) [1]

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#### Matching Treatment Benefits With Risk Profiles (Reduction in Body Weight Effect on CVD Risk Factors, Events, Morbidity and Mortality) (DO NOT EDIT)

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Class I

"1. Counsel overweight and obese adults with CV risk factors (high BP, hyperlipidemia and hyperglycemia), that lifestyle changes that produce even modest, sustained weight loss of 3%-5% produce clinically meaningful health benefits, and greater weight losses produces greater benefits.

* Sustained weight loss of 3%-5% is likely to result in clinically meaningful reductions in triglycerides, blood glucose, HbA1C, and the risk of developing type 2 diabetes;
* Greater amounts of weight loss will reduce BP, improve LDL–C and HDL–C, and reduce the need for medications to control BP, blood glucose and lipids as well as further reduce triglycerides and blood glucose. (Level of Evidence: A)"

#### Diets for Weight Loss (Dietary Strategies for Weight Loss) (DO NOT EDIT)

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Class I

"1. Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss, as part of a comprehensive lifestyle intervention. Any 1 of the following methods can be used to reduce food and calorie intake:

* Prescribe 1,200–1,500 kcal/day for women and 1,500–1,800 kcal/day for men (kcal levels are usually adjusted for the individual’s body weight);
* Prescribe a 500 kcal/day or 750 kcal/day energy deficit; or
* Prescribe one of the evidence-based diets that restricts certain food types (such as high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake. (Level of Evidence: A)"

"2. Prescribe a calorie-restricted diet, for obese and overweight individuals who would benefit from weight loss, based on the patient’s preferences and health status and preferably refer to a nutrition A (Strong) professional* for counseling. A variety of dietary approaches can produce weight loss in overweight and obese adults, as presented in CQ3, ES2. (Level of Evidence: A)"

### ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death - Obesity, Dieting, and Anorexia (DO NOT EDIT) [5]

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Class I

"1. Life-threatening ventricular arrhythmias in patients with obesity, anorexia, or when dieting should be treated in the same manner that such arrhythmias are treated in patients with other diseases, including ICD and pacemaker implantation as required. Patients receiving ICD implantation should be receiving chronic optimal medical therapy and have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: C) "
Class III

"1. Prolonged, unbalanced, very low calorie, semistarvation diets are not recommended; they may be harmful and provoke life-threatening ventricular arrhythmias. (Level of Evidence: C)"
Class IIa

"1. Programmed weight reduction in obesity and carefully controlled re-feeding in anorexia can effectively reduce the risk of ventricular arrhythmias and SCD. (Level of Evidence: C)"

### ACP 2005 Guidelines for Pharmacologic and surgical management of obesity in primary care[6]

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In a clinical practice guideline by the American College of Physicians, the following five recommendations are made:[2]

1. People with a BMI of over 30 should be counseled on diet, exercise and other relevant behavioral interventions, and set a realistic goal for weight loss.
2. If these goals are not achieved, pharmacotherapy can be offered. The patient needs to be informed of the possibility of side-effects and the unavailability of long-term safety and efficacy data.
3. Drug therapy may consist of sibutramine, orlistat, phentermine, diethylpropion, fluoxetine, and bupropion. For more severe cases of obesity, stronger drugs such as amphetamine and methamphetamine may be used on a selective basis. Evidence is not sufficient to recommend sertraline, topiramate, or zonisamide.
4. In patients with BMI > 40 who fail to achieve their weight loss goals (with or without medication) and who develop obesity-related complications, referral for bariatric surgery may be indicated. The patient needs to be aware of the potential complications.
5. Those requiring bariatric surgery should be referred to high-volume referral centers, as the evidence suggests that surgeons who frequently perform these procedures have fewer complications.

A clinical practice guideline by the US Preventive Services Task Force (USPSTF) concluded that the evidence is insufficient to recommend for or against routine behavioral counseling to promote a healthy diet in unselected patients in primary care settings, but that intensive behavioral dietary counseling is recommended in those with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians.[7][8]

## Exercise

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Exercise requires energy (calories). Calories are stored in body fat. The body breaks down its fat stores in order to provide energy during prolonged aerobic exercise. The largest muscles in the body are the leg muscles, and naturally these burn the most calories, which make walking, running, and cycling among the most effective forms of exercise for reducing body fat.

A meta-analysis of randomized controlled trials by the international Cochrane Collaboration found that "exercise combined with diet resulted in a greater weight reduction than diet alone".[9]

## Dieting

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Main article: Dieting

In general, dieting means eating less. Various dietary approaches have been proposed, some of which have been compared by randomized controlled trials:

* A comparison of Dr. Atkins', Slim-Fast's, Weight Watchers', and Rosemary Conley's diets found no significant differences.[10]
* A comparison of Atkins diet, Zone diet, Weight Watchers, and Ornish diet noted:[11]

"all 4 diets resulted in modest statistically significant weight loss at 1 year, with no statistically significant differences between diets"
"The higher discontinuation rates for the Atkins and Ornish diet groups suggest many individuals found these diets to be too extreme"

### Low Carbohydrate versus Low Fat

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Main article: Medical research related to low-carbohydrate diets

Many studies have focused on diets that reduce calories via a low-carbohydrate (Atkins diet, Zone diet) diet versus a low-fat diet (LEARN diet, Ornish diet). The Nurses' Health Study, an observational cohort study, found that low carbohydrate diets based on vegetable sources of fat and protein are associated with less coronary heart disease.[12]

A meta-analysis of randomized controlled trials by the international Cochrane Collaboration in 2002 concluded[13] that fat-restricted diets are no better than calorie restricted diets in achieving long term weight loss in overweight or obese people.

A more recent meta-analysis that included randomized controlled trials published after the Cochrane review[14][15][11] found that "low-carbohydrate, non-energy-restricted diets appear to be at least as effective as low-fat, energy-restricted diets in inducing weight loss for up to 1 year. However, potential favorable changes in triglyceride and high-density lipoprotein cholesterol values should be weighed against potential unfavorable changes in low-density lipoprotein cholesterol values when low-carbohydrate diets to induce weight loss are considered."[16]

The Women's Health Initiative Randomized Controlled Dietary Modification Trial[17] found that a diet of total fat to 20% of energy and increasing consumption of vegetables and fruit to at least 5 servings daily and grains to at least 6 servings daily resulted in:

* No reduction in cardiovascular disease[18]
* An insignificant reduction in invasive breast cancer[19]
* No reductions in colorectal cancer[20]

Additional recent randomized controlled trials have found that:

* A comparison of Atkins, Zone diet, Ornish diet, and LEARN diet in premenopausal women found the greatest benefit from the Atkins diet.[21]

* The choice of diet for a specific person may be influenced by measuring the invididual's insulin secretion:

In young adults "Reducing glycemic [carbohydrate] load may be especially important to achieve weight loss among individuals with high insulin secretion."[22] This is consistent with prior studies of diabetic patients in which low carbohydrate diets were more beneficial.[23][24]

### Low Glycemic Index

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"The glycaemic index factor is a ranking of foods based on their overall effect on blood sugar levels. Low glycaemic index foods, such as lentils, provide a slower more consistent source of glucose to the bloodstream, thereby stimulating less insulin release than high glycaemic index foods, such as white bread."[25][26]

The glycemic load is "the mathematical product of the glycemic index and the carbohydrate amount".[27]

In a randomized controlled trial that compared four diets that varied in carbohydrate amount and glycemic index found complicated results[28]:

* Diet 1 and 2 were high carbohydrate (55% of total energy intake)
* Diet 1 was high-glycemic index
* Diet 2 was low-glycemic index
* Diet 3 and 4 were high protein (25% of total energy intake)
* Diet 3 was high-glycemic index
* Diet 4 was low-glycemic index

Diets 2 and 3 lost the most weight and fat mass; however, low density lipoprotein fell in Diet 2 and rose in Diet 3. Thus the authors concluded that the high-carbohydrate, low-glycemic index diet was the most favorable.

A meta-analysis by the Cochrane Collaboration concluded that low glycemic index or low glycemic load diets led to more weight loss and better lipid profiles. However, the Cochrane Collaboration grouped low glycemic index and low glycemic load diets together and did not try to separate the effects of the load versus the index.[25]

## Drugs

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Main article: Anti-obesity drug

## References

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1. ↑ 1.0 1.1 Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, Donato KA; et al. (2013). "2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society". Circulation. doi:10.1161/01.cir.0000437739.71477.ee. PMID 24222017.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
2. ↑ 2.0 2.1 Snow V, Barry P, Fitterman N, Qaseem A, Weiss K, Clinical Efficacy Assessment Subcommittee of the American College of Physicians (2005). "Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians". Ann Intern Med. 142 (7): 525–31. PMID 15809464.CS1 maint: Multiple names: authors list (link)
3. ↑ 3.0 3.1 Garvey WT, Garber AJ, Mechanick JI, Bray GA, Dagogo-Jack S, Einhorn D; et al. (2014). "American association of clinical endocrinologists and american college of endocrinology consensus conference on obesity: building an evidence base for comprehensive action". Endocr Pract. 20 (9): 956–76. doi:10.4158/EP14279.CS. PMID 25253226.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
4. ↑ 4.0 4.1 Yumuk V, Tsigos C, Fried M, Schindler K, Busetto L, Micic D; et al. (2015). "European Guidelines for Obesity Management in Adults". Obes Facts. 8 (6): 402–24. doi:10.1159/000442721. PMID 26641646.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
5. ↑ Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M; et al. (2006). "ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". Circulation. 114 (10): e385–484. doi:10.1161/CIRCULATIONAHA.106.178233. PMID 16935995.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
6. ↑ Snow V, Barry P, Fitterman N, Qaseem A, Weiss K (2005). "Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians". Ann Intern Med. 142 (7): 525–31. PMID 15809464.CS1 maint: Multiple names: authors list (link)  Fulltext.
7. ↑ "Behavioral counseling in primary care to promote a healthy diet: recommendations and rationale". Retrieved 2007-05-22.
8. ↑ Pignone MP, Ammerman A, Fernandez L; et al. (2003). "Counseling to promote a healthy diet in adults: a summary of the evidence for the U.S. Preventive Services Task Force". American journal of preventive medicine. 24 (1): 75–92. PMID 12554027.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
9. ↑ Shaw K, Gennat H, O'Rourke P, Del Mar C (2006). "Exercise for overweight or obesity". Cochrane database of systematic reviews (Online) (4): CD003817. doi:10.1002/14651858.CD003817.pub3. PMID 17054187.CS1 maint: Multiple names: authors list (link)
10. ↑ Truby H, Baic S, deLooy A; et al. (2006). "Randomised controlled trial of four commercial weight loss programmes in the UK: initial findings from the BBC "diet trials"". BMJ. 332 (7553): 1309–14. doi:10.1136/bmj.38833.411204.80. PMID 16720619.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
11. ↑ 11.0 11.1 Dansinger ML, Gleason JA, Griffith JL, Selker HP, Schaefer EJ (2005). "Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial". JAMA. 293 (1): 43–53. doi:10.1001/jama.293.1.43. PMID 15632335.CS1 maint: Multiple names: authors list (link)
12. ↑ Halton TL, Willett WC, Liu S; et al. (2006). "Low-carbohydrate-diet score and the risk of coronary heart disease in women". N. Engl. J. Med. 355 (19): 1991–2002. doi:10.1056/NEJMoa055317. PMID 17093250.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
13. ↑ Pirozzo S, Summerbell C, Cameron C, Glasziou P (2002). "Advice on low-fat diets for obesity". Cochrane database of systematic reviews (Online) (2): CD003640. PMID 12076496.CS1 maint: Multiple names: authors list (link)
14. ↑ Samaha FF, Iqbal N, Seshadri P; et al. (2003). "A low-carbohydrate as compared with a low-fat diet in severe obesity". N. Engl. J. Med. 348 (21): 2074–81. doi:10.1056/NEJMoa022637. PMID 12761364.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
15. ↑ Foster GD, Wyatt HR, Hill JO; et al. (2003). "A randomized trial of a low-carbohydrate diet for obesity". N. Engl. J. Med. 348 (21): 2082–90. doi:10.1056/NEJMoa022207. PMID 12761365.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
16. ↑ Nordmann AJ, Nordmann A, Briel M; et al. (2006). "Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials". Arch. Intern. Med. 166 (3): 285–93. doi:10.1001/archinte.166.3.285. PMID 16476868.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
17. ↑ Howard BV, Manson JE, Stefanick ML; et al. (2006). "Low-fat dietary pattern and weight change over 7 years: the Women's Health Initiative Dietary Modification Trial". JAMA. 295 (1): 39–49. doi:10.1001/jama.295.1.39. PMID 16391215.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
18. ↑ Howard BV, Van Horn L, Hsia J; et al. (2006). "Low-fat dietary pattern and risk of cardiovascular disease: the Women's Health Initiative Randomized Controlled Dietary Modification Trial". JAMA. 295 (6): 655–66. doi:10.1001/jama.295.6.655. PMID 16467234.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
19. ↑ Prentice RL, Caan B, Chlebowski RT; et al. (2006). "Low-fat dietary pattern and risk of invasive breast cancer: the Women's Health Initiative Randomized Controlled Dietary Modification Trial". JAMA. 295 (6): 629–42. doi:10.1001/jama.295.6.629. PMID 16467232.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
20. ↑ Beresford SA, Johnson KC, Ritenbaugh C; et al. (2006). "Low-fat dietary pattern and risk of colorectal cancer: the Women's Health Initiative Randomized Controlled Dietary Modification Trial". JAMA. 295 (6): 643–54. doi:10.1001/jama.295.6.643. PMID 16467233.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
21. ↑ Gardner CD, Kiazand A, Alhassan S; et al. (2007). "Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial". JAMA. 297 (9): 969–77. doi:10.1001/jama.297.9.969. PMID 17341711.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
22. ↑ Ebbeling CB, Leidig MM, Feldman HA, Lovesky MM, Ludwig DS (2007). "Effects of a low-glycemic load vs low-fat diet in obese young adults: a randomized trial". JAMA. 297 (19): 2092–102. doi:10.1001/jama.297.19.2092. PMID 17507345.CS1 maint: Multiple names: authors list (link)
23. ↑ Stern L, Iqbal N, Seshadri P; et al. (2004). "The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial". Ann. Intern. Med. 140 (10): 778–85. PMID 15148064.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
24. ↑ Garg A, Bantle JP, Henry RR; et al. (1994). "Effects of varying carbohydrate content of diet in patients with non-insulin-dependent diabetes mellitus". JAMA. 271 (18): 1421–8. PMID 7848401.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
25. ↑ 25.0 25.1 Thomas D, Elliott E, Baur L (2007). "Low glycaemic index or low glycaemic load diets for overweight and obesity". 3: CD005105. doi:10.1002/14651858.CD005105.pub2. PMID 17636786.CS1 maint: Multiple names: authors list (link)
26. ↑ Jenkins DJ, Wolever TM, Taylor RH; et al. (1981). "Glycemic index of foods: a physiological basis for carbohydrate exchange". Am. J. Clin. Nutr. 34 (3): 362–6. PMID 6259925.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
27. ↑ Brand-Miller JC, Thomas M, Swan V, Ahmad ZI, Petocz P, Colagiuri S (2003). "Physiological validation of the concept of glycemic load in lean young adults". J. Nutr. 133 (9): 2728–32. PMID 12949357.CS1 maint: Multiple names: authors list (link)
28. ↑ McMillan-Price J, Petocz P, Atkinson F; et al. (2006). "Comparison of 4 diets of varying glycemic load on weight loss and cardiovascular risk reduction in overweight and obese young adults: a randomized controlled trial". Arch. Intern. Med. 166 (14): 1466–75. doi:10.1001/archinte.166.14.1466. PMID 16864756.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)

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