Elsevier

Mayo Clinic Proceedings

Volume 82, Issue 1, January 2007, Pages 93-102
Mayo Clinic Proceedings

CONCISE REVIEW FOR CLINICIANS
Treatment of Obesity

https://doi.org/10.4065/82.1.93Get rights and content

For primary care physicians, obesity is one of the most challenging problems confronted in office practice. The disorder is increasing in prevalence despite the efforts of both patients and physicians. Treatment requires a multimodality approach that addresses diet, physical activity, and behavioral issues. Medication and surgical approaches may be appropriate as well. This review outlines the evidence for each approach, suggests how primary care physicians can best help obese patients, and provides practical tips for weight loss.

Section snippets

DIETS

Many different diets have been advocated for weight loss, but there is little scientific evidence to recommend one diet over another. Dansinger et al10 compared 4 approaches, the Atkins (low carbohydrate), Zone (high protein, low carbohydrate), Ornish (very low fat), and Weight Watchers diets, and found no significant difference in weight loss at 1 year. Other studies have shown greater weight loss at 3 months with low-carbohydrate than with other diets but no significant difference at 1 year.11

DRUGS

The role of medications in weight loss is controversial, and their effectiveness appears to be limited. First, the amount of weight lost with use of drugs is small (as discussed subsequently). Second, the long-term safety of weight-loss drugs is not established, and the occurrence of adverse effects (such as the cardiac valve abnormalities associated with fenfluramine) suggests that this is an important consideration. Finally, when weight-loss drugs are discontinued, weight is regained. Because

BARIATRIC SURGERY

Bariatric surgery rates have increased substantially,35 but this procedure may still be underused.36 Although no long-term randomized trials have been conducted, bariatric surgery is the only treatment that has been reported to result in substantial 10-year weight loss.37, 38 Bariatric surgery results in long-term reduction in energy intake and is associated with increased physical activity.37 Furthermore, morbidity from obesity can be altered substantially by bariatric surgery. In a recent

Physical Activity

Most studies have demonstrated no or modest weight loss with exercise alone (2 kg) or with exercise added to diet (3 kg).50, 51 However, 2 studies of longer-duration exercise (90-120 minutes daily) combined with constant energy intake showed weight losses of 7 to 8 kg.52, 53 The amount of time spent exercising appears to be more important than exercise intensity.54

Evidence from randomized trials regarding the importance of exercise in weight maintenance is sparse.50, 51 However, observational

FACILITATING BEHAVIOR CHANGE

Changing patients' long-term behavior to increase energy expenditure and decrease energy intake is one of the biggest challenges facing primary care physicians. Other health care professionals can be of great assistance in this effort. Dietitians can help patients reduce energy intake by providing instruction on portion size, energy values of foods, and menu planning. Exercise therapists and trainers can tailor exercise programs to the patient and encourage long-term compliance. Behavioral

PUTTING IT ALL TOGETHER

Combining the weight-loss strategies discussed herein is more likely to produce success than use of any single strategy alone. The LEARN program, a self-help system designed for use in health care settings, combines many of the modalities discussed in this article and can get patients started in the right direction.94 Table 2 provides a similarly helpful summary of behavioral techniques for weight loss, and readers are encouraged to give a photocopy of this table to their patients. Behavioral

Questions About the Treatment of Obesity

(Detailed information regarding answers to each question is available at www.mayoclinicproceedings.com linked to this article.)

  • 1.

    A 47-year-old woman was evaluated 3 months previously for obesity management. She had gastroesophageal reflux disease and hoped that losing weight would improve the condition. Her family history was remarkable for diabetes mellitus in her mother and myocardial infarction in her paternal grandfather at age 74 years. She had never smoked cigarettes. Physical examination

REFERENCES (96)

  • SS Malinowski

    Nutritional and metabolic complications of bariatric surgery

    Am J Med Sci

    (2006)
  • BM Craig et al.

    Cost-effectiveness of gastric bypass for severe obesity

    Am J Med

    (2002)
  • DR Bensimhon et al.

    Obesity and physical activity: a review

    Am Heart J

    (2006)
  • G Foster

    The behavioral approach to treating obesity

    Am Heart J

    (2006)
  • RL Weinsier et al.

    Free-living activity energy expenditure in women successful and unsuccessful at maintaining a normal body weight

    Am J Clin Nutr

    (2002)
  • JA Levine et al.

    Energy expenditure of nonexercise activity

    Am J Clin Nutr

    (2000)
  • MA Pereira et al.

    Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis [published correction appears in Lancet. 2005;365:1030]

    Lancet

    (2005)
  • M Bes-Rastrollo et al.

    Predictors of weight gain in a Mediterranean cohort: the Seguimiento Universidad de Navarra Study

    Am J Clin Nutr

    (2006)
  • DB Allison et al.

    Annual deaths attributable to obesity in the United States

    JAMA

    (1999)
  • KM Flegal et al.

    Excess deaths associated with underweight, overweight, and obesity

    JAMA

    (2005)
  • GA Colditz

    Economic costs of obesity and inactivity

    Med Sci Sports Exerc

    (1999)
  • CL Ogden et al.

    Prevalence of overweight and obesity in the United States, 1999-2004

    JAMA

    (2006)
  • RS Stafford et al.

    National trends in antiobesity medication use

    Arch Intern Med

    (2003)
  • CB Ruser et al.

    Identification and management of overweight and obesity by internal medicine residents

    J Gen Intern Med

    (2005)
  • RE McArtor et al.

    Family practice residents' identification and management of obesity

    Int J Obes Relat Metab Disord

    (1992)
  • ML Dansinger et al.

    Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial

    JAMA

    (2005)
  • GD Foster et al.

    A randomized trial of a low-carbohydrate diet for obesity

    N Engl J Med

    (2003)
  • L Stern et al.

    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

    (2004)
  • CB Ebbeling et al.

    A reduced-glycemic load diet in the treatment of adolescent obesity

    Arch Pediatr Adolesc Med

    (2003)
  • WG Thompson et al.

    Effect of energy-reduced diets high in dairy products and fiber on weight loss in obese adults

    Obes Res

    (2005)
  • SK Raatz et al.

    Reduced glycemic index and glycemic load diets do not increase the effects of energy restriction on weight loss and insulin sensitivity in obese men and women

    J Nutr

    (2005)
  • A Due et al.

    Effect of normal-fat diets, either medium or high in protein, on body weight in overweight subjects: a randomised 1-year trial

    Int J Obes Relat Metab Disord

    (2004)
  • BV Howard et al.

    Low-fat dietary pattern and weight change over 7 years: the Women's Health Initiative Dietary Modification Trial

    JAMA

    (2006)
  • DG Schlundt et al.

    Randomized evaluation of a low fat ad libitum carbohydrate diet for weight reduction

    Int J Obes Relat Metab Disord

    (1993)
  • BJ Rolls et al.

    Provision of foods differing in energy density affects long-term weight loss

    Obes Res

    (2005)
  • TA Wadden et al.

    Randomized trial of lifestyle modification and pharmacotherapy for obesity

    N Engl J Med

    (2005)
  • CK Haddock et al.

    Pharmacotherapy for obesity: a quantitative analysis of four decades of randomized clinical trials

    Int J Obes Relat Metab Disord

    (2002)
  • DE Arterburn et al.

    The efficacy and safety of sibutramine for weight loss: a systematic review

    Arch Intern Med

    (2004)
  • Z Li et al.

    Meta-analysis: pharmacologic treatment of obesity

    Ann Intern Med

    (2005)
  • FX Pi-Sunyer et al.

    Effect of rimonabant, a cannabinoid-1 receptor blocker, on weight and cardiometabolic risk factors in overweight or obese patients: RIO-North America: a randomized controlled trial [published correction appears in JAMA. 2006;295:1252]

    JAMA

    (2006)
  • DG Simons-Morton et al.

    Obesity research—limitations of methods, measurements, and medications [editorial]

    JAMA

    (2006)
  • MH Davidson et al.

    Weight control and risk factor reduction in obese subjects treated for 2 years with orlistat: a randomized controlled trial [published correction appears in JAMA 1999;281: 1174]

    JAMA

    (1999)
  • JS Torgerson et al.

    XENical in the prevention of diabetes in obese subjects (XENDOS) study: a randomized study of orlistat as an adjunct to lifestyle changes for the prevention of type 2 diabetes in obese patients [published correction appears in Diabetes Care. 2004;27: 856]

    Diabetes Care

    (2004)
  • TA Wadden et al.

    Effects of sibutramine plus orlistat in obese women following 1 year of treatment by sibutramine alone: a placebo-controlled trial

    Obes Res

    (2000)
  • HP Santry et al.

    Trends in bariatric surgical procedures

    JAMA

    (2005)
  • BM Wolfe et al.

    Weighing in on bariatric surgery: procedure use, readmission rates, and mortality [editorial]

    JAMA

    (2005)
  • L Sjöström et al.

    Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery

    N Engl J Med

    (2004)
  • H Buchwald et al.

    Bariatric surgery: a systematic review and meta-analysis [published correction appears in JAMA. 2005;293:1728]

    JAMA

    (2004)

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