Chapter One
The Treatment of Obesity: An Overview
THOMAS A. WADDEN SUZETTE OSEI
In 1998, an expert panel assembled by the National Heart, Lung, and Blood Institute (NHLBI, 1998) conducted an exhaustive review of the safety and efficacy of treatments for obesity. It issued recommendations for selecting among interventions, based on an individual's body mass index (BMI) and risk of health complications. The panel's lengthy report was distilled by a joint committee into the Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (NHLBI & North American Association for the Study of Obesity [NAASO], 2000). This briefer document provides primary care practitioners with additional guidelines and tools for treating overweight and obese individuals. Both of these documents are essential reading for persons interested in weight management.
This chapter adheres to the recommendations of the joint NHLBI and NAASO (2000) panel, and provides additional detail about various treatment options. The chapter seeks to help practitioners identify the most appropriate therapy for a given individual. As such, it offers a framework for selecting from the dietary, behavioral, pharmacological, surgical, and other interventions described in the chapters that follow this one.
SELECTING TREATMENT
The decision to initiate weight loss should be based on an assessment of a patient's need to reduce, as described in this volume by Atkinson (Chapter 9) and Aronne (Chapter 18), and on the individual's behavioral readiness for weight loss, as discussed by Wadden and Phelan (Chapter 10). These factors, together with the BMI, suggest which interventions are likely to be most appropriate for a particular patient.
Treatment Algorithms
Aronne (Chapter 18, this volume) has reviewed the NHLBI and NAASO (2000) algorithm for selecting therapy (see Table 18.4 on page 396). Persons with a BMI of 25.0-29.9 kg/[m.sup.2] who have two or more risk factors are encouraged to consume a balanced low-calorie diet, to increase their physical activity (so that they eventually exercise 30 minutes a day most days of the week), and to modify inappropriate eating habits. Alternatively, prevention of weight gain is recommended for persons in the same BMI range who are not motivated to reduce or who have fewer than two risk factors. As BMI increases, so generally do the health complications of obesity and the need for more intensive intervention. Pharmacotherapy is an option for persons with a BMI [greater than or equal to] 30 [kg/[m.sup.2] (or a BMI [greater than or equal to] 27 kg/[m.sup.2] in the presence of comorbid conditions) and who have failed to reduce using more conservative measures. Bariatric surgery is reserved for individuals with a BMI [greater than or equal to] 40 kg/[m.sup.2] or those with a BMI [greater than or equal to] 35 kg/[m.sup.2] who have significant comorbid conditions.
Wadden, Brownell, and Foster (in press) have proposed a stepped-care algorithm that, similar to that developed by the NHLBI and NAASO (2000) panel, recommends treatment based on the patient's BMI and risk of health complications (see Figure 11.1). The principal difference between the two schemes is the greater number of treatment options listed by the former algorithm and the stronger encouragement for persons with a BMI of 27-29 kg/[m.sup.2] to lose weight. The presence of a single risk factor, such as hypertension or Type 2 diabetes, would appear to provide ample reason to undertake weight loss. Moreover, prevention of weight gain for individuals who fall into the BMI range of 27-29 kg/[m.sup.2] is likely to require periodic bouts of caloric restriction, as well as increased physical activity, to reverse weight gain that occurs over the winter months or at other times. In overweight and obese adults, intentional weight loss, even when followed by weight regain, does not appear to be associated with (1) increased risks of morbidity or mortality, (2) adverse effects on metabolism or energy expenditure, or (3) the precipitation of eating disorders or depression (Foster, Sarwer, & Wadden, 1997; Gregg & Williamson, Chapter 7, this volume; National Task Force on the Prevention and Treatment of Obesity, 1994, 2000; Wadden, Foster, Stunkard, & Conill, 1996). Thus there do not appear to be strong reasons to dissuade persons with a BMI of 27-29 kg/[m.sup.2] from attempting to lose weight.
Treatment Selection
Treatment selection should be guided not only by the individual's BMI and health risks, but also by the patient's history of weight loss efforts. For example, we have encountered many obese males (BMI [greater than or equal to] 30 kg/[m.sup.2]) who were eligible for pharmacotherapy but who had never participated in a traditional behavioral program of diet and physical activity. The latter intervention is less expensive than pharmacotherapy and is associated with fewer risks of health complications. Pharmacotherapy may be useful with these individuals for maintaining weight loss, but is not necessary to induce it. By contrast, it is hard to argue that a woman with a BMI of 35 kg/[m.sup.2], Type 2 diabetes, and a marked history of weight cycling should enroll in yet another diet and exercise program. She is more likely to achieve long-term success with long-term pharmacotherapy or with bariatric surgery. Diet and activity modification will remain an important focus of treatment, but they would need to be supported by these other interventions. Patients should have tried a less intensive treatment option once or twice before selecting a more aggressive therapy, but it is not necessary to try the less intensive option again with each new practitioner.
Treatment options must also be selected with consideration of their safety, efficacy, and cost. Self-help programs, for example, are very attractive because of their safety and low cost, but they usually produce minimal weight loss (Womble, Wang, & Wadden, Chapter 19, this volume). Thus such programs may not be a good choice for an individual who needs to lose approximately 10% of initial weight to improve a weight-related health complication.
Individual preferences also must be considered. Given that patients must actively participate in their weight management (i.e., by modifying eating and activity habits and/or by taking medications), they must find the therapy acceptable. Concerns about the safety of some approaches, including pharmacotherapy or surgery, must be respected in view of the history of complications associated with these interventions. Similarly, patients may raise objections to specific diet or exercise regimens. A health care provider can suggest that a patient try a specific approach for a week or two, as an experiment, with the hope that it will prove acceptable. It is inappropriate, however, to push patients to accept a single diet or exercise plan when there are so few data to inform patient-treatment matching (i.e., tailoring). Clearly, one size does not fit all. Kumanyika has discussed, in Chapter 20 of this volume, the importance of responding to individual differences and preferences in selecting an appropriate weight loss intervention.
TREATMENT OPTIONS: BMI < 30 kg/[m.sup.2]
Approximately 36% of adult Americans have a BMI of 25.0-29.9 kg/[m.sup.2], placing them in the "overweight" category as defined by the NHLBI (1998) and the World Health Organization (1998). Surveys indicate that most of these individuals, when trying to lose weight, do so on their own-by dieting (i.e., restricting food intake), exercising, or both (Serdula, Collins, Williamson, Pamuk, & Byers, 1993). These persons also buy millions of diet books and exercise videos each year, although little is known about the effectiveness of these interventions.
Primary Care Physicians
Aronne (Chapter 18, this volume) has described the role of primary care physicians in preventing and treating obesity. This includes monitoring patients' weight (and BMI) on a regular basis, providing literature on healthy eating and activity habits, and assessing and managing weight-related health complications. Some physicians may wish to provide more intensive weight management, potentially by giving patients a structured treatment manual, having a registered dietitian consult in the office, or establishing an afternoon or evening clinic to provide brief check-in visits (i.e., to measure weight, collect food records, etc.).
Primary care physicians often report that they feel ill prepared to treat overweight individuals, whether because of lack of adequate training, poor reimbursement, or a sense of futility-a feeling "that nothing works" (Aronne, Chapter 18; Frank, 1993). Patients may well sense their physicians' lack of involvement. Nearly three-quarters of participants in a recent study reported that they looked to their doctors only a "slight amount" or "not at all" for advice about weight management (Wadden, Anderson, et al., 2000). Nearly 45% indicated that their doctor had not prescribed any of 10 common weight loss methods. These data suggest that physicians and their obese patients may have landed in a weight management stalemate: No one talks about the problem. On a more positive note, fewer than 10% of patients reported that they were treated disrespectfully by their doctors concerning their weight. Moreover, most respondents were quite satisfied with the medical care they received for their general health.
It is challenging for most primary care physicians to provide effective diet and exercise counseling in traditional office practice, because they are not equipped to meet with their patients on a weekly or biweekly basis-the frequency of care that is likely to produce the best results (at least in the short term). Nevertheless, physicians can play an important role in the management of overweight and obesity by providing an atmosphere in which patients can discuss their concerns and frustrations about their weight. Moreover, practitioners can provide a valuable service by familiarizing themselves with treatment options available in their community and using these resources (Aronne, Chapter 18). This includes identifying a registered dietitian with whom to establish a consultative relationship. (A local dietitian may be identified by calling 800-366-1655.) Physicians can similarly support their patients' participation in self-help or commercial programs by inquiring at office visits about satisfaction with these programs and congratulating patients on weight loss or behavior change.
Self-Help and Commercial Programs
Self-Help Programs
Overweight individuals who are unable to reduce on their own, or with their physicians' advice, may benefit from the greater structure and support provided by self-help and commercial programs (reviewed in this volume by Womble et al., Chapter 19). Self-help programs charge no fee or only a nominal one (e.g., a dollar per week), and yet may induce weight losses as large as those produced by some of the most expensive proprietary programs. Latner and colleagues (2000), for example, recently reported that participants in a highly structured, group behavioral self-help program lost an average of 17.9 kg during the first 2 years and maintained a mean loss of 15.7 kg at 5 years. The 5-year findings were based on only the 21.6% of participants who remained in the program at this time, but these are still impressive results, particularly in light of the negligible costs of the program. Take Off Pounds Sensibly (TOPS) and Overeaters Anonymous (OA) offer additional low- or no-cost alternatives that are available nationwide (see TOPS Club, 2000, and OA, 1996). Few data, however, are available to evaluate the effectiveness of these latter two programs (Womble et al., Chapter 19).
Commercial Programs
Outcome data have become increasingly important to commercial weight loss programs because providers can no longer make claims of long-term success unless they have data to support them. Not surprisingly, no commercial programs now advertise that their participants "lose weight and keep it off forever," as they did prior to the Federal Trade Commission's (1997) action against several companies.
Weight Watchers has taken the lead among commercial programs in evaluating its results of treatment. A recent study revealed that patients who were randomly assigned to attend a conventional Weight Watchers program lost 6.0% of initial weight in 6 months (Heshka et al., 2000). Persons assigned to a self-directed weight loss approach that included two meetings with a registered dietitian lost 2.5% of initial weight. These results indicate that the Weight Watchers program, which combines group support with a sound program of diet, exercise, and behavior modification, can be of benefit to overweight and obese individuals at a reasonable cost (i.e., about $12 per week). Participants, on average, do not lose large amounts of weight, but losing as few as 2-3 kg after the holidays would appear to be better than continuously gaining weight. Moreover, even if participants do not lose a lot of weight, they do not lose a lot of money. In the absence of efficacy data from other commercial programs, it is hard not to select Weight Watchers as a first intervention for overweight individuals who want more structure and cannot find a self-help program.
Behavioral Weight Loss Programs
Weight Watchers and other commercial programs have incorporated many of the components of the behavioral treatment of obesity that was developed in university clinics in the late 1960s (Stuart, 1967). Wing has described, in Chapter 14 of this volume, the theoretical underpinnings of the behavioral approach, as well as its short- and long-term treatment results. Patients typically lose 8%-10% of initial weight during 4-6 months of weekly group treatment (Wing, 1998, and Chapter 14, this volume). Approximately 80%-85% of participants complete treatment. Thus, traditional behavioral interventions are likely to produce greater weight loss than are most commercial programs, although this hypothesis has not been tested in randomized trials.
There are numerous accounts of the components of behavioral treatment, which include self-monitoring, stimulus control, problem solving, cognitive restructuring, social support, nutrition education, physical activity, and the use of reinforcement contingencies (Brownell, 2000; Wadden & Foster, 2000; Wing, 1998). Brownell (2000) has provided a 16-week, step-by-step manual that covers these topics in a detailed but user-friendly manner. Rather than repeat this description, this section briefly discusses some of the mechanics of behavioral treatment that we believe contribute to its successful induction of weight loss.
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Excerpted from Handbook of Obesity Treatment by Thomas A. Wadden Copyright © 2002 by Thomas A. Wadden. Excerpted by permission.
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