behavior changes, such as reducing grams of fat in the diet and increasing minutes of daily exercise. Stress management involves the use of problem-solving strategies to reduce or cope with stressful events. Meditation, relaxation procedures, and regular exercise are examples of stress-reducing techniques. Cognitive-behavioral strategies are used to help change a client's attitudes and beliefs about unrealistic expectations, appropriate goals, and body image. Examples include the use of affirmations (positive self-statements) and visual imagery (seeing oneself eating and exercising appropriately). The principles and techniques are tailored to each person's specific problems. Social support, usually from the family or a group, is used to maintain motivation and provide reinforcement for appropriate behavior changes. All behavioral principles are used to help individuals adhere to a healthy diet and exercise program.

Drug Therapy

There is increased interest in the use of medications to treat obesity, given the recent consensus that obesity is a chronic disease with biological and genetic bases that is affected by an environment promoting physical inactivity and consumption of energy-dense foods (Bouchard et al., 1990; Stunkard, 1990) (see Table 3-2). In reviews of short-term (< months), double-blind, placebo-controlled trials with 7,725 subjects, pharmacologic agents resulted in an average weight loss of 0.23 kg/week compared to placebo (Galloway et al., 1984; Goldstein and Potvin, 1994; Scoville, 1973).

In a review of 27 weight-reduction studies reported between 1967 and March 1992, Goldstein and Potvin (1994) examined the effect of drug therapy of at least 6 months' duration on weight loss and maintenance. The studies reviewed used a variety of agents, including dexfenfluramine, fluoxetine, mazindol, phentermine, and varied experimental designs. In those subjects who responded to drug therapy, weight loss leveled off after approximately 6 months. Goldstein and Potvin recommend that future research focus on identifying subgroups of individuals who are responsive and unresponsive to specific drugs.

If one compares obesity to other chronic diseases such as hypertension and non-insulin-dependent diabetes mellitus, obesity treatments should also include the option of using medication for periods longer than 6 months. However, few studies have investigated this option. In three studies, d-fenfluramine was studied for 52 weeks (Guy-Grand et al., 1989), fluoxetine for 52 weeks (Darga et al., 1991; Marcus et al., 1990), and the combination of phentermine and d,l-fenfluramine for 3.5 years (Weintraub et al., 1992a). In these studies, drugs helped to maintain lower body weight in a significant number of subjects without intolerable adverse



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