National Academies Press: OpenBook

Weighing the Options: Criteria for Evaluating Weight-Management Programs (1995)

Chapter: 3 Programs for and Approaches to Treating Obesity

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Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

3
Programs for and Approaches to Treating Obesity

The wide variety of weight-loss interventions can be placed along a continuum on the basis of many factors, including intensity of treatment, cost, nature of the intervention(s), and degree of involvement of health-care providers. So numerous are the options from which a person wishing to lose weight can choose that we consider them here only in summary form, illustrating three major categories of programs:

  • Do-it-yourself programs

  • Nonclinical programs

  • Clinical programs

This grouping is not meant to imply that one should progress from one category to the next (i.e., one with a higher level of treatment intensity) if weight loss was not successful or only somewhat so. The next treatment option to try depends on the individual's state of health, the amount of weight to lose, his or her evaluation of the need for outside help, and other considerations.

The first part of this chapter consists of brief descriptions of do-it-yourself, nonclinical, and clinical programs. Following this, we discuss the broad approaches to treating obesity used within each of these categories of programs. These approaches include diet, physical activity, behavior modification, drug therapy, and gastric surgery.

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

TYPES OF WEIGHT-LOSS PROGRAMS

Do-It-Yourself Programs

Do-it-yourself programs are individually formulated and therefore extraordinarily varied. This category includes any effort by an individual to lose weight by himself or herself or with a group of like-minded others, through programs such as Overeaters Anonymous and TOPS (Take Off Pounds Sensibly) or community-based and work-site programs. Individual judgment, books, products, and group therapy may dispense good or bad advice. The common denominator of programs in this category is that outside resources are not used in a personalized or individualized manner. We have identified five general subcategories of self-help programs:

One subcategory includes the individual who is losing weight with a personally formulated low-calorie program with or without exercise, regardless of the safety or other characteristics of this effort. A second subcategory involves those who derive guidance from popular published materials such as books or magazines with diet instructions. A third subcategory includes those who use any of a number of popularly promoted products such as diet aids, low-calorie foods, and meal replacements. A fourth subcategory includes those who participate in a group as a source of counseling, advice, structure, or reinforcement. The fifth subcategory includes those participating in community-based and work-site programs.

Nonclinical Programs

Nonclinical programs are popular and are often commercially franchised. They typically have a structure created by a parent company and often use instructional and guidance materials that are prepared in consultation with health-care providers. The qualifying characteristic of these programs is that they rely substantially on variably trained counselors (who are not health-care providers by our definition) to provide services to the individual client. However, these programs are often managed or advised by qualified and licensed health-care providers. They may or may not sell prepared food products, meal replacements, or other products to their clients. Many popular weight-loss centers offer advice on nutrition, physical activity, and behavior modification, which is provided at weekly classes or meetings. Specific outcomes of any of these programs are unknown, since little or no published data are available (Stunkard, 1992).

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

Clinical Programs

In clinical programs, services are provided by a licensed professional who may or may not have received special training to treat obese patients. The programs may or may not be a part of a commercial franchise system. There are two subgroups within this category. One is the program in which an individual professional provider is working alone. It is assumed that, although the provider has the ability to refer the patient for special consultation, the services are in fact provided by the individual professional (psychologist, dietitian, physician, etc.) who is the focus of the therapeutic effort. The service provider may be providing such services as a very-low-calorie (formula) diet or medications. The other subcategory is a program that includes a multidisciplinary group of professional providers working together and systematically coordinating their efforts, records, and patient base. Their efforts may include such services as nutrition, medical care, behavior therapy, exercise, and psychological counseling, and they may utilize very-low-calorie diets, medications, and surgery. For the most part, specific outcomes of these individual programs are unknown.

We have provided characteristics of specific, well-known weight-loss programs in Table 3-1. We adapted and expanded this table, originally presented in Ward (1994), using materials and comments supplied by most of the programs described. The reader should not misconstrue this information as an endorsement or rejection by us of any of these programs. It was not the intent of this report to evaluate specific programs.

TABLE 3-1 A Comparison of Popular Weight-Loss Programs

DO-IT-YOURSELF PROGRAMS

Overeaters Anonymous (OA)

Approach/Method

Nonprofit international organization that provides volunteer support groups worldwide patterned after the 12-step Alcoholics Anonymous program. Addresses physical, emotional, and spiritual recovery aspects of compulsive overeating. Members encouraged to seek professional help for individualized diet/nutrition plan and for any emotional or physical problems.

Clients

Individuals who define themselves as compulsive eaters.

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

Staff

Nonprofessional volunteer group members who meet specific criteria lead meetings, sit on the board, and conduct activities.

Expected Weight Loss/Length of Program

Makes no claims for weight loss. Unlimited length.

Cost

Self-supporting with member contributions and sales of publications (includes workbooks, tapes, newsletters, and sponsor outreach programs. Its international monthly journal, Lifeline, costs $12.99/year.

Healthy Lifestyle Components

Recommends emotional, spiritual, and physical recovery changes. Makes no exercise or food recommendations.

Comments

Inexpensive. Provides group support. No need to follow a specific diet plan to participate. Minimal organization at the group level, so groups vary in approach. No health-care providers on staff.

Availability

10,500 groups in 47 countries. Headquarters: Rio Rancho, NM (505) 891-2664.

TOPS (Take Off Pounds Sensibly)

Approach/Method

Nonprofit support organization of 310,000 members who meet weekly in groups. Does not prescribe or endorse particular eating or exercise regimen. Mandatory weigh-in at weekly meetings. Provides peer support. Uses award programs for healthy lifestyle changes; special recognition given to best weight losers. Members who maintain their goal weight loss for 3 months become members of KOPS (Keep Off Pounds Sensibly).

Clients

Members must submit weight goals and diets obtained from a health professional in writing.

Staff

Each group elects a volunteer (non-health professional) to direct and organize activities

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

for one year. Health professionals, including R.D.s and psychologists, may be invited to speak at weekly meetings. Organization consults with a medical advisor.

Expected Weight Loss/Length of Program

No claims made for weight loss. Unlimited length.

Cost

First visit free. $16 annual fee ($20 in Canada) for the first 2 years; $14 annually thereafter ($18 in Canada). Includes 40-page quarterly magazine from company headquarters. Weekly meetings cost 50 cents to $1.

Healthy Lifestyle Components

No official lifestyle or exercise recommendations, but endorses slow, permanent lifestyle changes. Members encouraged to consult health-care provider for an exercise regimen to meet their needs.

Comments

Inexpensive form of continuing group support. Used as adjunct to professional care. Nonprofit and noncommercial, so no purchases required. Encourages long-term participation. Lacks professional guidance at chapter level since meetings run by volunteers. Groups vary widely in approach.

Availability

11,700 chapters in 20 countries, mostly U.S. and Canada. Headquarters: Milwaukee, WI (800) 932-8677.

NONCLINICAL PROGRAMS

Diet Center

Approach/Method

Focuses on achieving healthy body composition through diet and personalized exercise recommendations under the name Exclusively You Weight Management Program. Diet based on regular supermarket food; Diet Center prepackaged cuisine is optional. Body-fat analysis via electrical impedance taken at start of program and every 4 to 6 weeks thereafter. Clients encouraged to visit center daily for weigh-in. Calorie levels individualized to meet client needs and goals. Minimum level: 1,200 kcal/day. Four phases: 2-day conditioning phase prepares dieter for reducing. Reducing phase used until goal achieved. Stabilization, the third phase, has clients adjusting calories and physical activity to maintain weight. Maintenance, the fourth phase, lasts for 1 year. One-to-one counseling. Some group meetings available.

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

Clients

Not allowed to join: pregnant, lactating, anorectic, bulimic, and underweight individuals, and those under 18 years of age. Require physician's written approval: those with more than 50 pounds to lose, kidney or heart disease, diabetes, cancer, or emphysema.

Staff

Clients consult with nonprofessional counselors who typically are program graduates trained by Diet Center. Two staff R.D.s and scientific advisors made up of a variety of health professionals design program at corporate level.

Expected Weight Loss/Length of Program

Not more than 1.5 to 2 pounds weekly. Length will vary with individualized client goals, but 1-year maintenance program strongly encouraged.

Cost

Varies. Ranges from about $35 to $50/week. The 1-year maintenance is a one-time flat fee ranging from $50 to $200. Some centers charge additional one-time fee for all body composition analyses and adjustments in diet and exercise goals.

Healthy Lifestyle Components

Exclusively Me behavior management, as an ongoing part of the program, includes an activity book, audio tapes, and counseling. Used in conjunction with regular one-to-one sessions; counselor helps client design personal solutions to weight-control problems.

Comments

Emphasizes body composition, not pounds, as a measure of health. Does not require the purchase of Diet Center food for participation. Professional guidance lacking at the client level. Little group support available. Vitamin supplement required.

Availability

700 centers in U.S., Canada, Bermuda, Guam, and South America. Headquarters: Pittsburgh, PA (800) 333-2581.

Jenny Craig

Approach/Method

Personal Weight Management menu plans based on Jenny Craig's cuisine with additional store-bought foods. Diet ranges from 1,000 to 2,600 kcal, depending on client needs. Mandatory weekly one-to-one counseling; group workshops. After clients lose half their goal, they begin planning their own meals using their own foods.

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

Clients

Not allowed to join: individuals who are underweight, pregnant, or those below age 13; those with celiac disease, diabetes (who inject more than twice daily or who are under 18 years of age), or allergies to ubiquitous ingredients in company's food products. Require physician's written permission: individuals with 18 additional conditions. Regardless of condition, clients encouraged to communicate with personal physician throughout program.

Staff

Program developed by corporate R.D.s and psychologists. Company consults with advisory board of M.D.s, R.D.s, and Ph.D.s on program design. Consultants trained by Jenny Craig to implement program and offer support and motivational strategies. Corporate dietitians available for client questions or concerns at no extra charge.

Expected Weight Loss/Length of Program

Clients encouraged to set reasonable weight goals based on personal history and healthy weight standards. Program designed to produce weight loss of 1 to 2 pounds/week. A separate, 12-month maintenance program is also offered.

Cost

To join: $99 to $299, depending on option. Prices vary per inclusion of home audio-and videocassettes. Most expensive price includes Lifestyle Maintenance program. Jenny Craig cuisine costs average $70 weekly.

Healthy Lifestyle Components

Clients use program guides to learn cognitive behavioral techniques for relapse prevention and problem management for lifestyle changes. Based on individual priorities, clients address major factors involved with weight management (e.g., exercise, which is addressed through a physical activity module and a walking program). Individual consultations; group workshops provide motivation and peer exchange. The Lifestyle Maintenance program addresses issues such as body image and maintaining motivation to exercise.

Comments

Little food preparation. Vegetarian and kosher meal plans available; also plans for diabetic, hypoglycemic, and breastfeeding clients. Recipes provided. Must rely on Jenny Craig cuisine for participation. Lack of professional guidance at client level.

Availability

800 centers in five countries; 650 centers in U.S. Headquarters: Del Mar, CA (800) 94-JENNY.

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

Nutri/System

Approach/Method

Menu plans based on Nutri/System's prepared meals with additional grocery foods. Clients receive individual calorie levels ranging from 1,000 to 2,200 kcal/day. Multivitamin-mineral supplement available for clients. Personal counseling and group sessions available.

Clients

Not allowed to join: individuals who are pregnant, under 14 years of age, underweight, or anorectic. Require physician's written permission: lactating women and those with a variety of conditions including diabetes (if require insulin shots), heart disease (that limits normal activity), and kidney disease.

Staff

Staff dietitians, health educators, and Ph.D.s develop program at corporate level. Scientific Advisory Board consisting of M.D.s and Ph.D.s employed for program design. Counselors with education and experience in psychology, nutrition, counseling, and health-related fields provide weekly guidance to clients. Certified Personal Trainers administer the Personal Trainer Program developed in conjunction with Johnson & Johnson Advanced Behavioral Technologies, Inc. R.D.s available through a toll-free number to address client questions.

Expected Weight Loss/Length of Program

Averages 1.5 to 2 pounds/week. Clients select weight goal based on a recommended weight range using standard tables. Program length varies with weight-loss goals.

Cost

Varies. Clients can lose all desired weight for $99. Unlimited service program costs $249. Food costs average $49/week. Vitamin-mineral supplements, at-home cholesterol test, motivational audiotapes, and exercise audio/videocassettes available at additional cost.

Healthy Lifestyle Components

Wellness and Personal Trainer services developed in conjunction with Johnson & Johnson Health Management have been added to the program.

Comments

Few decisions about what to eat; relatively rigid diet with company foods. Portion-controlled Nutri/System foods allow dieters to focus more on making lifestyle changes than on the reducing diet. Program provides both Wellness and Personal Trainer services. Little contact with health professionals.

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

Availability

650 centers in U.S. and Canada. Headquarters: Horsham, PA (215) 442-5411.

Weight Watchers

Approach/Method

Emphasis on portion control and healthy lifestyle habits. Dieters choose from regular supermarket food, Weight Watchers Personal Cuisine (available in select markets to members only), or both. Reducing phase: Women average 1,250 kcal daily; men, 1,600 daily. Levels for weight maintenance determined individually. Weekly group meetings with mandatory weigh-in. Must need to lose at least 5 pounds to join.

Clients

Not allowed to join: those not weighing at least 5 pounds above the lowest end of their healthy weight range and those with a medically diagnosed eating disorder. Require physician's written approval: pregnant and lactating women and children under 10 years of age.

Staff

Group leaders are non-health professional graduates of program (Lifetime Members) trained by Weight Watchers. Program developed by corporate R.D.s. Company consults with medical advisor and advisory board consisting of M.D.s and Ph.D.s on program design. Health professionals at corporate level, including R.D.s, direct program.

Expected Weight Loss/Length of Program

Up to 2 pounds weekly. Unlimited length. Special 2-week Superstart program offers more rapid initial weight loss. Maintenance plan is 6 weeks.

Cost

$17–$20 to join; $10–$13 weekly. Fee entitles member to unlimited meetings for that week. Monthly meetings are free for Lifetime Members who have completed maintenance plan and maintain their weight goal within 2 pounds. Personal Cuisine prices vary, averaging about $70 weekly.

Healthy Lifestyle Components

Emphasizes making positive lifestyle changes, including regular exercise. Encourages daily minimum physical activity level.

Comments

Flexible program offering group support and well-balanced diet. Vegetarian plan available, plus healthy eating plans for pregnant and breastfeeding women. Encourages

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

long-term participation for members to attain their weight-loss goals. Lacks professional guidance at client level. No personalized counseling except in select markets.

Availability

29,000 weekly meetings in 24 countries. Headquarters: Jericho, NY (516) 939-0400.

CLINICAL PROGRAMS

Health Management Resources (HMR)

Approach/Method

Medically supervised very-low-calorie diet (VLCD) of fortified, high-protein liquid meal replacements (520 to 800 kcal daily) or a low-calorie option consisting of liquid supplements and prepackaged HMR entrees (800 to 1,300 kcal daily). Dieters receive HMR Risk Factor Profile that measures and displays an individual's medical and lifestyle health risks. Mandatory weekly 90-minute group meetings. Maintenance meetings are 1 hour per week. One-to-one counseling. Need to have BMI >30 for VLCD.

Clients

Contraindications: pregnancy, lactation, and acute substance abuse. Require physician's written approval: some with acute psychiatric disorders, recent heart disease, cancer, renal or liver disease, insulin-dependent diabetes mellitus, and those who test positive for acquired immunodeficiency syndrome (AIDS).

Staff

Program developed by M.D.s, R.D.s, R.N.s, and psychologists. Each location has at least one M.D. and health educator on staff. Participants assigned ''personal coaches" (R.D.s, exercise physiologists, health educators) who help dieters learn and practice weight-management skills. Dieters on VLCD see M.D. or R.N. weekly.

Expected Weight Loss/Length of Program

Averages 2 to 5 pounds weekly. Reducing phase varies according to weight-loss needs, but averages 12 weeks; refeeding phase (after liquids only) lasts about 6 weeks. Maintenance program recommended for up to 18 months.

Cost

Varies depending on diet chosen and medical conditions. Ranges from $80 to $130/week including medical visits. Cost may be covered by insurance. Maintenance is $60–$90/month.

Healthy Lifestyle Components

Recommends every client burn a minimum of 2,000 kcal in physical activity weekly.

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

Advocates consuming a diet with no more than 30 percent of calories from fat and at least 35 servings of fruits and vegetables per week. Emphasizes lifestyle issues in weekly classes and in personal coaching.

Comments

Emphasizes exercise as a means for weight loss and control. Few decisions about what to eat. Supervised by a health professional. Requires a strong commitment to physical activity. Side effects of VLCD may include intolerance to cold, constipation, dizziness, dry skin, and headaches. All options include liquid supplement; diet is very high in protein, even at higher calorie levels.

Availability

180 hospitals and medical settings nationwide. Headquarters: Boston, MA (617) 357-9876.

Medifast

Approach/Method

Medifast is a physician-supervised very-low-calorie diet program of fortified meal replacements containing 450-500 kcal/day. LifeStyles—The Medifast Program of Patient Support® prepares patients to maintain their goal weight after completing the VLCD. Medifast also provides a low-calorie diet of approximately 860 kcal/day for those not indicated for the VLCD.

Clients

Contraindications: those who are not at least 30 percent above ideal body weight, those who have not reached sexual and physical maturation, pregnant and lactating women, those with a history of cerebrovascular accident, and those with conditions such as anorexia nervosa, bulimia, recent myocardial infarction, unstable angina, insulin-dependent diabetes, thrombophlebitis, active cancer, and uncompensated renal or hepatic disease.

Staff

Program supervised by a physician. At the corporate level, a medical advisory board of M.D.s, Ph.D.s, and R.D.s is consulted on program development.

Expected Weight Loss/Length of Program

Physician and patient arrive at an individualized goal weight. Metropolitan Life Insurance Company tables, Dietary Guidelines for Americans, and BMI charts used as guides. Weight loss varies with individual; average weight loss is 3–5 pounds/week. Weight Reduction Phase lasts 16 weeks and Realimentation Phase lasts 4–6 weeks. Maintenance strongly encouraged for up to 1 year.

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

Cost

Cost for office visits, laboratory tests, and Medifast products vary by individual physician. The program ranges from $65 to $85/week. Costs may be covered by insurance.

Healthy Lifestyle Components

The Medifast program includes a comprehensive education program called LifeStyles that includes behavior modification, recommended physical activity, and nutrition education. Instruction booklets and patient guides provided, including quarterly newsletter to patients.

Comments

Close contact with one or more health professionals. Low calorie level promotes quick weight loss. Extensive product line. Company products and regular foods incorporated when VLCD not recommended. Must rely on company products during reducing phase. Maintenance program assists with transition to regular foods.

Availability

15,000 physicians nationwide, primarily in office-based settings, and in six foreign countries. Headquarters: Jason Pharmaceuticals, Inc., Owings Mills, MD (410) 581-8042.

New Direction

Approach/Method

The New Direction System includes a medically supervised VLCD program of fortified meal replacements with 600–840 kcal/day. The OUTLook and ShapeWise programs are moderate-calorie programs of 1,000–1,500 kcal/day and include the use of regular food and fortified bars and beverages.

Clients

Contraindications to VLCD: women with less than 40 pounds to lose and men with less than 50 pounds to lose (except in special cases), those less than 18 years of age, pregnant and lactating women, and those with conditions such as insulin-dependent (type I) diabetes, metastatic cancer, recent myocardial infarction, liver disease requiring protein restriction, and renal insufficiency.

Staff

Weekly sessions in the New Direction and OUTLook programs are led by health professionals with degrees in dietetics, exercise physiology, behavioral counseling, or related fields. One-on-one counseling in each discipline is part of the program. Each program has a medical director.

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

Expected Weight Loss/Length of Program

In the New Direction program, average weight losses of 3 pounds/week after the first few weeks are common. In the OUTLook and ShapeWise programs, losses greater than 2 pounds/week are grounds for concern (after the first 2 weeks). The Reducing Phase averages 12–16 weeks, the Adapting Phase (with transition to regular food) lasts 5 weeks, and the Sustaining Phase is a minimum of 6 months (12 months preferred). Ongoing continuing care is encouraged.

Cost

Varies with the program chosen, amount of weight to lose, and medical conditions. An approximate range is $40/week in the OUTLook and ShapeWise programs; $110–$120/week in the Reducing Phase of the VLCD and $0–$20/week in the later phases. Costs may be covered by insurance.

Healthy Lifestyle Components

Weekly classes have a strong behavioral component with an emphasis on problem-solving and lifestyle-skills development in nutrition and exercise.

Comments

Individualized care and close contact with health professionals. Must rely on company products during the Reducing Phase of VLCD program. Transition from VLCD to regular food requires supervision. Low calorie level promotes quick weight loss, most beneficial for people with certain health problems. Clients make few decisions about what to eat while on the VCLD. OUTLook and ShapeWise programs include regular food.

Availability

Headquarters: Ross Products Division, Abbott Laboratories, Columbus, OH (614) 624-7573.

Optifast

Approach/Method

Medically supervised program of fortified liquid meal replacements and/or fortified food bars, eventually including more regular foods. Dieters assigned an 800-, 950-, or 1,200-kcal plan. Weekly sessions on how to change eating behavior and one-to-one counseling.

Clients

Not allowed to join: individuals less than 30 percent or less than 50 pounds over desirable weight (corresponding to a BMI of approximately 30–32) and those less than 18 years of age. Contraindications for the low-calorie protocol include pregnant and

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

lactating women and individuals with recent acute myocardial infarction or unstable angina, insulin-dependent (type I) diabetes mellitus, and advanced liver or kidney disease.

Staff

Dieters seen regularly by M.D.s, R.N.s, R.D.s, and psychologists at most locations; exercise physiologist used on consulting basis. Group meeting leaders are psychologists or dietitians. Meetings often include R.D.s. Clients assigned case manager who coordinates care.

Expected Weight Loss/Length of Program

Program limits weight loss to 2 percent of body weight weekly. Active Weight Loss Plan lasts for about 13 weeks. Transition phase lasts for about 6 weeks. Maintenance, which begins at 20th week, is encouraged. No time limit on maintenance.

Cost

Varies with type of diet and length of program. Costs range from $1,500 to $3,000, depending on health status and the amount of weight to lose. Price may include maintenance at some centers. Insurance may cover a portion of cost.

Healthy Lifestyle Components

Emphasis on behavior modification and diet planning for "real food" in group and counseling sessions. Exercise physiologist available to help design personal exercise plan.

Comments

Close contact with health professionals. Controlled calorie level promotes quick weight loss, most beneficial for people with certain health problems. Clients make few decisions about what to eat. Must rely on Optifast products during reducing phase.

Availability

Numerous hospitals and clinics in U.S. and foreign countries. Headquarters: Sandoz Nutrition, Minneapolis, MN (800) 662-2540.

Physicians in a Multidisciplinary Program

Approach/Method

Multidisciplinary programs may provide a program similar to HMR, New Direction, or Optifast. They may also provide food-based weight-loss programs or modifications of the two approaches. The multidisciplinary aspect implies the coordination of services, the availability of individual and/or group counseling, and comprehensive medical care.

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

Staff

Typically physicians, dietitians, behavior therapists, exercise physiologists, psychologists, and counselors working individually and in group settings. Service providers should be licensed and regulated and should have their activities scrutinized by peers.

Expected Weight Loss/Length of Program

Variable and adapted to the needs of patient. There should be a maintenance program with continuing patient access to services for sustaining care and reinforcement. Patient use of medications and consequences of surgery will be monitored.

Cost

Varies with approach used and duration. Some programs will use a standard professional fee-for-service schedule of charges; others will use a single charge for a comprehensive set of services for a specified period of time. Potential for reimbursement from health-insurance plans. A packaged set of services may be substantially less expensive than the individual services in a fee-for-service arrangement.

Health Lifestyle Components

Varies. All recognized factors in weight management will be considered.

Comments

Similar to, but more extensive, services than physicians working alone. Professional staff coordinates all aspects of care and long-term management of obesity. Diverse staff is able to adapt care to the needs of patients, including the management of associated medical problems. These are often university-based programs, which have structured peer-review mechanisms and may conduct research. Costs for professional services tend to be high.

Availability

Very limited.

OTHERS

Registered Dietitians (R.D.s.)

Approach/Method

Highly personalized approach to weight loss and maintenance.

Clients

Those acceptable and not acceptable will vary with the R.D.

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

Staff

R.D.s have, at a minimum, baccalaureate degrees in nutrition or closely related field and have completed approved or accredited clinical training. Often have advanced degrees. R.D.s must pass a registration examination given by the Commission on Dietetic Registration of the American Dietetic Association and participate in continuing education.

Expected Weight Loss/Length of Program

Varies according to weight goal. Clients rarely encouraged to lose more than 2 pounds weekly.

Cost

Varies across the country, but can range from $35 to $150 per hour. Fees for weight-control groups may be substantially less than for individual counseling.

Healthy Lifestyle Components

Exercise encouraged as part of safe, sensible weight-control program. R.D.s help clients identify barriers to weight loss and maintenance, and provide education about healthy lifestyles.

Comments

Highly adaptable. Personalized approach to clients' health concerns. Trained health professionals who can address medical history and account for it in diet therapy, if necessary. Appropriate for any age group. Can be expensive.

Availability

Located in every state in private practice, outpatient hospital clinics, health maintenance organizations (HMOs), and in practice with M.D.s. For a free referral to a local R.D., call (800) 366-1655.

Physicians Practicing Alone

Approach/Method

Individualized approach to weight loss and maintenance. Patients able to coordinate the management of their weight with concurrent management of associated medical problems. Services can be adapted to specific needs. Options include medications and surgery to treat obesity.

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

Staff

Individual physicians possibly working with associates (e.g., nurses and physicians' assistants). Provision of services by licensed professional health-care providers.

Expected Weight Loss/Length of Program

Varies with patient. Program may be of indefinite length and should be coordinated with care of related or unrelated medical issues.

Cost

Varies. Fees will be comparable to those charged for comparable medical services. Cost may be reduced by reimbursement from health-insurance companies and avoidance of duplication of services in referrals for medical care by nonprofessional programs.

Healthy Lifestyle Components

Varies with the physician and weight-loss approach. Should include exercise and nutrition counseling.

Comments

Professional care. Coordination with other medical problems. Appropriate for patients with complex or serious associated medical problems. Long-term attention in the context of other medical care can be provided. The potential for using medications and/or surgery expands the opportunities for patients at varying stages of their disease. Individual physicians have the ability to vary the patient's care and intensity of the effort depending on the patient's life circumstances. Physicians often inadequately trained in nutrition and in low-calorie physiology. Cost for services can be high.

Availability

Generally available, but many physicians are reluctant to treat obesity because of their lack of interest or training, recognition that support services that they cannot provide are needed, and concern for the limited usefulness of their intervention.

 

SOURCE: Ward, 1994. Copyright 1994 by Environmental Nutrition, Inc., 52 Riverside Drive, New York, NY 10024-6599. Adapted and expanded with permission. Descriptions reviewed by organizations for accuracy.

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

APPROACHES TO TREATMENT

We have identified five broad approaches to treatment used by the do-it-yourself, nonclinical, and clinical programs: diet, physical activity, behavior modification, drug therapy, and gastric surgery. Not all approaches are used by, or available to, each category of programs. However, each program category uses one or more of these approaches.

Diets

Balanced-Deficit Diets

Balanced-deficit diets provide 1,200 or more kcal/day and are usually nutritionally adequate, providing at least the minimum recommended number of servings from all major food groups. Many published diet books outline balanced-deficit diets, although not all are sensible (Dwyer and Lu, 1993). Balanced-deficit diets require little, if any, medical supervision except, for example, under circumstances in which the diet or resulting weight loss might alter a person's underlying medical condition and result in the need for management.

Low-Calorie Diets

Low-calorie diets provide approximately 800–1,200 kcal/day. Some of these diets utilize regular foods, while others are designed to use specially formulated or fortified products and prepackaged foods. A typical low-calorie diet is designed to provide no more than 25 percent of calories as fat, but many find it difficult to achieve and maintain such a low-fat intake. A low-calorie diet utilizing only regular foods may require vitamin-mineral supplementation to meet the nutritional needs of the client. Commercial low-calorie diet programs include Weight Watchers, Diet Workshop, Diet Center, Jenny Craig, and Nutri/System, all of which are based on the use of regular foods, prepackaged foods (which may be optional or required), and/or dietary supplements from the company. (These programs may provide balanced-deficit diets as well.) All of these programs use a multidisciplinary approach with combined diet, exercise, and behavior change.

Many low-calorie diets are also self-administered. Some over-the-counter diet products include Sweet Success (Nestlé) and Slim Fast. These diet products are specially formulated powders or foods designed as meal replacements. Weight loss with low-calorie diets averages approximately 0.5 to 1.5 kg/week (8.5 kg over 20 weeks) (NTF, 1993). Other low-calorie diets described in books range from low-fat, high-carbohydrate diets to

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

nutritionally unbalanced diets void of any scientific basis (Dwyer and Lu, 1993).

Low-calorie diets are safe for patients who have comorbid conditions such as diabetes, hyperlipidemia, or hypertension. However, they should be followed only with physician approval and supervision by a health-care provider since the patient may become ketotic and dehydrated, especially if the diet is very low in carbohydrate (Dwyer and Lu, 1993). In addition, patients on medication (e.g., oral glucose-lowering agents) may require changes in their medication schedule or amount because of energy restriction and weight loss. The overwhelming majority of participants on low-calorie diets regain their weight lost within 5 years (NIH Technology Assessment Conference Panel, 1993), and the attrition rate in commercial programs is very high (e.g., more than 60 percent over 20 weeks) (Stunkard, 1992).

Very-Low-Calorie Diets

Very-low-calorie diets (VLCDs) are modified fasts providing less than 800 kcal/day, and they replace usual food. Most VLCD programs are based in hospitals or clinics and include the commercial programs Opti-fast, Medifast, New Direction, and Health Management Resources (HMR) (Dwyer and Lu, 1993). They are medically supervised and administered by a multidisciplinary team including physicians, behavioral therapists, dietitians, exercise physiologists, and nurses. The most common VLCDs are formulations designed to supply 45–100 grams (0.8–1.5 g/kg of ideal body weight) per day of protein of high biological value (coming primarily from dairy sources, soy, or albumin); up to 100 grams of carbohydrate; a minimum of fat as essential fatty acids; and recommended allowances of vitamins, minerals, and electrolytes (NTF, 1993).

VLCDs are generally limited to moderately and severely obese individuals with a body mass index (BMI) of greater than 30 who have failed to lose weight by more conventional methods, but they may be appropriate for patients with a BMI of 27 to 30 who have a comorbid condition. Designed to generate a larger and more rapid weight loss than low-calorie diets, they are usually prescribed for 12 to 16 weeks (NTF, 1993). VLCDs have rapid, positive effects on the health of obese patients with comorbid conditions (Kanders and Blackburn, 1993). Improvements in glycemic control, decreases in systolic and diastolic blood pressure, and decreases in serum concentrations of total cholesterol, low-density-lipoprotein cholesterol, and triglycerides occur within 3 weeks.

In controlled clinical trials, VLCDs resulted in an average total loss of 20 kg over 12 weeks. In contrast, low-calorie diets combined with behavioral treatment produced an average loss of 8.5 kg over 20 to 24 weeks.

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

However, the vast majority of patients on VLCDs regain the weight within 5 years (Miura et al., 1989; Sikand et al., 1988; Wadden et al., 1989; Wing et al., 1991a). VLCDs are quite expensive compared to low-calorie diets; out-of-pocket expenses can exceed $3,500 for the diet itself, medical evaluation and monitoring, individual counseling, and group classes.

Physical Activity

Although most of the do-it-yourself, nonclinical, and clinical programs mention physical activity, it frequently appears to be an afterthought, rather than an integral part of the intervention. Physical activity ranges in intensity from walking to vigorous activities, such as jogging and bicycling. The more vigorous the activity, the more the body's energy stores are utilized. Each individual should develop a realistic goal for increasing activity, starting with a low level that feels comfortable and progressing slowly to higher levels. One key to maintaining an increased level of physical activity is finding the kinds of activities that engage one's interests and can be fit into one's lifestyle and constraints on time. There are few studies of recidivism associated with exercise, though recidivism appears to be high (Dishman, 1988, 1991; Foreyt and Goodrick, 1994). Obesity treatment programs should include a systematically planned and integrated physical activity intervention in order to develop a lifestyle change associated with increased physical activity and thus energy expenditure.

Behavior Modification

Behavior modification is a methodology aimed at helping individuals identify the idiosyncratic problems and barriers interfering with their weight loss and management. Specific behavioral principles are used to solve these problems. No obesity-treatment program can afford to ignore this treatment approach. The principles used in behavior modification typically include self-monitoring, stimulus control, contingency management, stress management, cognitive behavioral strategies, and social support.

Self-monitoring consists of two steps: self-observation and self-recording of those observations. Food and exercise diaries are used to assess the client's eating habits and activity levels. Stimulus control involves identifying the environmental cues associated with unhealthy eating and under-exercising. Modifying the cues often involves strategies such as limiting eating to specific times and places, buying food when not hungry, and laying out exercise clothing to encourage a regular habit of physical activity. Contingency management includes the use of rewards for appropriate

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

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

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

TABLE 3-2 Appetite-Suppressing Drugs

Noradrenergic Agents

DEAa Schedule

Trade Name

Half-Life (hours)

Dosage Size (mg)

Daily Dose Range (mg)

Benzphetamine

III

Didrex

6–12

25; 50

25–150

Phendimetrazine

III

Anorex; Obalan; Phendiet; Plegine; Wehless; and others

5–12

35

70–210

Diethylpropion

IV

Tenuate; Tepanol

4–6

25; 75 (slow release)

75

Mazindol

IV

Mazanor; Sanorex

10

1 or 2

1–3

Phentermine

IV

Fastin; Ionamin; Phentrol; Adipex-P; and others

12–24

8; 15; 30

15–37.5

Phenylpropanolamine

Over the counter

Dexatrim

7–24

25 or 75

25–75

Serotonergic agents

Fenfluramine (d- or d-l)

IV

Pondimin

11–30

20

60–120

Fluoxetine

Not scheduled

Prozac; Lovan

24–72

20; 60

60

a DEA = Drug Enforcement Agency. See box titled ''Unreasonable Standards for Anti-Obesity Drugs?" for an explanation of the schedule classification.

SOURCE: Reproduced with permission, from G.A. Bray. Use and abuse of appetite-suppressant drugs in the treatment of obesity. Ann. Intern. Med. 1993;119:707–713.

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

UNREASONABLE STANDARDS FOR ANTI-OBESITY DRUGS?

Do the standards used to evaluate drugs for the treatment of obesity differ from those applied to drugs to treat other chronic diseases? A drug for treating hypertension, for example, is considered efficacious if blood pressure decreases when the drug is taken. The drug is not required to continue to lower blood pressure further as therapy continues, nor is the patient judged to have failed when blood pressure increases after the medication is withdrawn. This is also the case for drugs used to treat diabetes, asthma, and schizophrenia or to lower blood cholesterol concentrations. For any specific drug, however, a patient may or may not respond in the desired manner.

In sharp contrast to antihypertensives and lipid-lowering drugs, anti-obesity drugs are expected to work for most obese patients independent of the etiology of the disease. Furthermore, there is an expectation that drugs will continue to lower body weight until a desirable weight is reached and will maintain the weight loss even after the drug is discontinued (Atkinson and Hubbard, 1994). One example of this expectation is the fact that medical practice review boards and/or state regulations in nearly all states prohibit prescribing anti-obesity drugs for longer than 3 months (personal communication, Richard L. Atkinson, M.D., Professor of Medicine and Nutritional Sciences, University of Wisconsin, Madison). These circumstances suggest that a double standard exists for the use of anti-obesity drugs. We suggest that these drugs be judged effective if they can produce small but medically significant weight losses and be used for maintenance of weight loss.

After evaluating the views of Pi-Sunyer and Campfield (personal communications at committee workshop, December 1993), we believe that anti-obesity drugs should be considered effective when their use in combination with a sound program of diet and exercise results in (1) achievement of weight loss of at least 5 percent of initial body weight and maintenance of that loss; (2) reduced body weight through a reduction of body fat with a sparing of body protein; (3) reduction of comorbidities; and (4) minimum or tolerable side effects and low abuse potential.

It should be noted that patients most appropriate for drug therapy include those with comorbidities (e.g., hypertension, hyperglycemia, dyslipidemias, and sleep apnea) that can be diminished with weight loss and those at high risk for obesity-related comorbidities. We recommend that the U.S. Food and Drug Administration (FDA), which must approve all prescription drugs, focus on the pathogenesis of obesity as a chronic disease and evaluate drugs for its treatment in that light.

Drugs either approved or in development for treating obesity may decrease energy intake (e.g., serotonin uptake inhibitors, peptide-based appetite suppressants), increase energy expenditure or thermogenesis (e.g., beta-adrenergic receptor agonists), stimulate lipolysis (e.g., alpha-adrenergic receptor antagonists), or decrease fat or other macronutrient absorption (e.g., pancreatic lipase inhibitors) (Bray, 1993c; Goldstein and Potvin, 1994).

A question arises as to why this country has lagged so far behind other countries in the approval and use of anti-obesity drugs. In the United States, no new drugs have been approved for the treatment of obesity since 1972 (Atkinson and Hubbard, 1994). For example, d-fenfluramine, approved in Europe and much of

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

the rest of the world for some years, is still pending approval in this country. Furthermore, fluoxetine, approved in this country to treat depression and obsessive-compulsive disorder, has been under consideration by FDA for the treatment of obesity for more than 6 years (personal communication, Richard L. Atkinson, M.D.). Some of the barriers include a common view shared by the lay public, health-care providers, and government administrators that obesity is not a disease (Atkinson and Hubbard, 1994). Atkinson and Hubbard (1994) note that "obesity drugs are held to higher standards than drugs used for other diseases. Although it is generally agreed that obesity is a chronic disease, obesity drugs are limited to short-term use, no longer than a few weeks. Physicians who prescribe obesity drugs for longer periods are subject to scrutiny by State Medical Review Boards and may face loss of licensure." In contrast to current medical practice, Stallone and Stunkard (1992) have proposed that appetite-suppressant medication be used on a long-term basis or not at all.

Research on anti-obesity drugs has been hindered by fears of the abuse potential of these medications and previous indiscriminate prescription of these drugs by some physicians (Atkinson and Hubbard, 1994). This is also reflected in the Drug Enforcement Agency's classification of anti-obesity drugs. Schedule II drugs have a high abuse potential, Schedule III some abuse potential, and Schedule IV low abuse potential. The initial appetite-suppressant drugs (amphetamine, meth-amphetamine, and phenmetrazine), appropriately classified as Schedule II, are no longer in use. Other drugs in use, with little evidence of abuse potential, are still classified so that they are recommended for no more than a few weeks (personal communication, F. Xavier Pi-Sunyer, Chief, Division of Endocrinology, Diabetes, and Nutrition at St. Luke's/Roosevelt Hospital Center, New York City).

In three major studies of longer-term drug therapy (Darga et al., 1991; Marcus et al., 1990; Weintraub et al., 1992a, b), drugs helped some subjects maintain lower weights, and there is some indication the drugs may help change behavior. According to the work of Weintraub et al. (1992a, b), a combination of two types of drugs may be more effective for long-term weight loss and weight maintenance than either used alone. Because of regulation, use of medications is limited to the short term, no longer than a few weeks (Atkinson and Hubbard, 1994). Some physicians, however, may prescribe such drugs "off label," meaning not approved by FDA, for longer periods of time.

effects compared to controls. When medication was discontinued, weight was regained, and when medication was reintroduced, there was additional weight loss (Weintraub et al., 1992b). Not all individuals responded to drug treatment. As with other chronic diseases, it is unrealistic to expect that one therapeutic drug would be effective for all individuals.

Weintraub (1994) suggests that the standard crossover design in evaluating the effectiveness of a weight-management drug, in which subjects initially receive the drug and others the placebo and then at some point are switched to the other modality, is not appropriate. Subjects do not return to their baseline state before starting the next treatment. Weintraub believes that some of the variability in response to drug treatment can be

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

reduced by a 3- to 6-week "run-in" period during which subjects are started on ancillary therapy, including calorie restriction, behavior modification, and exercise. One can then assess the degree of commitment of the subjects and their response to the ancillary therapy prior to drug treatment. Drug treatment is then added to the ancillary therapy. Weintraub encourages use of this approach when treating obese patients with drugs for weight management.

A National Institutes of Health workshop on the pharmacological treatment of obesity concluded that "obesity drugs produce short-term weight loss and may remain effective for extended periods of time in some patients" (Atkinson and Hubbard, 1994). Nevertheless, drugs should be used as only one component of a comprehensive weight-reduction program that includes attention to diet, activity, and behavior modification. According to Silverstone (1993), these drugs should be limited to patients who are medically at risk because of their condition, among which he includes those with a BMI of 30 or greater or those with a comorbid condition.

Gastric Surgery

Because of its unique nature, the special requirements of participating patients, and the characteristics of the services implied in this type of program, the surgical treatment of obesity is a special subcategory of clinical programs. Two proven surgical procedures exist for the treatment of severe and very severe obesity: vertical banded gastroplasty and Roux-en-Y gastric bypass. Vertical banded gastroplasty consists of constructing a small pouch with a restricted outlet along the lesser curvature of the stomach. Roux-en-Y gastric bypass involves constructing a proximal gastric pouch whose outlet is a Y-shaped limb of small bowel of varying lengths (NIH, 1992). Vertical banded gastroplasty is less complex to perform and has fewer perioperative complications than gastric bypass, but produces less long-term weight loss (Sugerman et al., 1989). On the other hand, a higher risk of nutritional deficiencies exists following gastric bypass (NIH, 1992). Intestinal bypass surgery is no longer recommended as a surgical option to treat obesity (NIH, 1992).

The risk-benefit ratio must be evaluated for each patient when deciding if surgery should be utilized. Patients who have failed with nonsurgical measures and who are well informed and motivated may be considered. They must be able to participate in treatment and long-term follow-up. A BMI greater than 40 indicates the patient may be a potential candidate for surgical treatment (NIH, 1992). Patients with a BMI between 35 and 40 may be considered if they have high-risk comorbid conditions such as life-threatening cardiopulmonary problems or severe diabetes

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

mellitus (NIH, 1992). Obesity-induced physical problems that interfere with lifestyle, for example, joint disease treatable but for obesity, may also be an indication for surgery for patients with a BMI between 35 and 40 (NIH, 1992).

Substantial weight loss generally occurs within 12 months of the operation, with some of the weight being regained within 2 to 5 years. With weight loss comes improvement in the comorbid conditions that often accompany obesity. The risks associated with the surgical treatment of obesity include postoperative complications, micronutrient deficiencies, "dumping syndrome," and late postoperative depression (NIH, 1992).

There is compelling evidence that comorbidities are reduced in severely obese patients who have lost weight as a result of gastric surgery. Therefore, it is puzzling that this treatment is not more widely used for severely obese individuals at very high risk for obesity-related morbidity and mortality. It is possible that health-care providers and individuals alike fail to fully understand the severity and costs of obesity in terms of both increased morbidity and mortality and its impact on the quality of life. Perhaps there is also an intrinsic fear of the dangers of surgery due in part to lack of knowledge. In fact, mortality associated with gastric surgery for obesity is less than 1 percent (Kral, 1992). It has been proposed that most of the complications associated with this type of surgery, unlike most other surgery, are modifiable by behavior. For example, Kral (1994) notes that the vomiting seen in approximately 10 percent of patients after surgery is due more to eating behavior than to stenosis or stricture of the gastroplasty stoma. Another reason for the limited use of gastric surgery for obesity is that it is not always reimbursable (Chase, 1994). In the Swedish Obesity Study, patients in the surgical intervention group reported marked improvements in health, mood, and obesity-specific problems compared to controls (Näslund, 1994). This same study estimated that 7 percent of the costs to the work force of lost productivity due to sick leave and disability pension are related to obesity. Obesity surgery would profit from cost-benefit analyses that include the social and psychological benefits that many experience from the procedure.

Weight-loss surgery clearly involves hospital care. Any surgical program should be supported by appropriate nutritional, medical, and psychological counseling for the long-term management of the patients enrolled, although some programs of this kind in fact have no such support systems.

CONCLUDING REMARKS

This chapter has provided an overview of the many weight-loss programs, which are organized for convenience into three major categories,

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
×

and the five broad approaches to treatment used by them. In most cases, do-it-yourself, nonclinical, and clinical programs may be appropriate for people at any level of overweight, and some are also applicable for people who are not overweight but who want to obtain information and learn skills to keep from developing a weight problem. Anti-obesity drugs produce short-term weight loss and may remain effective for extended periods, so regulatory policies at the state and federal levels may need to be modified to permit use of these agents by appropriate individuals for longer periods of time than often allowed at present. Surgery is an option only for individuals whose BMI exceeds 40 or for those with a BMI of 35–40 suffering from high-risk comorbid conditions. Recommended programs will almost always include a focus on improving diet, increasing physical activity, and modifying behaviors that lead to weight gain.

In the following section of this report, Chapters 4 through 8, we present a conceptual overview of decisionmaking and use it to develop criteria and a model for evaluating obesity-treatment programs. The Weighing the Options model presented in Chapter 8 provides a framework for the conduct of programs that should help consumers choose more wisely from among available programs and be more successful at long-term weight loss.

Suggested Citation:"3 Programs for and Approaches to Treating Obesity." Institute of Medicine. 1995. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, DC: The National Academies Press. doi: 10.17226/4756.
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Nearly one out of every three adults in America is obese and tens of millions of people in the United States are dieting at any one time. This has resulted in a weight-loss industry worth billions of dollars a year and growing. What are the long-term results of weight-loss programs? How can people sort through the many programs available and select one that is right for them? Weighing the Options strives to answer these questions.Despite widespread public concern about weight, few studies have examined the long-term results of weight-loss programs. One reason that evaluating obesity management is difficult is that no other treatment depends so much on an individual's own initiative and state of mind.

Now, a distinguished group of experts assembled by the Institute of Medicine addresses this compelling issue. Weighing the Options presents criteria for evaluating treatment programs for obesity and explores what these criteria mean--to health care providers, program designers, researchers, and even overweight people seeking help.

In presenting its criteria the authors offer a wealth of information about weight loss: how obesity is on the rise, what types of weight-loss programs are available, how to define obesity, how well we maintain weight loss, and what approaches and practices appear to be most successful.

Information about weight-loss programs--their clients, staff qualifications, services, and success rates--necessary to make wise program choices is discussed in detail.

The book examines how client demographics and characteristics--including health status, knowledge of weight-loss issues, and attitude toward weight and body image--affect which programs clients choose, how successful they are likely to be with their choices, and what this means for outcome measurement. Short- and long-term safety consequences of weight loss are discussed as well as clinical assessment of individual patients.

The authors document the health risks of being overweight, summarizing data indicating that even a small weight loss reduces the risk of disease and depression and increases self-esteem. At the same time, weight loss has been associated with some poor outcomes, and the book discusses the implications for program evaluation.

Prevention can be even more important than treatment. In Weighing the Options, programs for population groups, efforts targeted to specific groups at high risk for obesity, and prevention of further weight gain in obese individuals get special attention.

This book provides detailed guidance on how the weight-loss industry can improve its programs to help people be more successful at long-term weight loss. And it provides consumers with tips on selecting a program that will improve their chances of permanently losing excess weight.

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