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Until recently, obesity was considered to be the direct result of a sedentary lifestyle plus chronic ingestion of excess calories Although these factors are undoubtedly the principal cause in
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mately 15% of initial weight Most programs use meal replacement diets to achieve the very-low-calorie intake Long-term weight maintenance is less predictable and requires concurrent behavior modification, long-term use of low-calorie diets, careful self-monitoring, and regular exercise Side effects such as fatigue, orthostatic hypotension, cold intolerance, and fluid and electrolyte disorders are observed in proportion to the degree of calorie reduction and require regular supervision by a physician Other less common complications include gout, gallbladder disease, and cardiac arrhythmias Although weight loss is more rapidly achieved with very-low-calorie diets as compared with traditional diets, long-term outcomes are equivalent Medications for the treatment of obesity are available both over the counter and by prescription Considerable controversy exists as to the appropriate use of medications for obesity NIH clinical obesity guidelines state that obesity drugs may be used as part of a comprehensive weight loss program for patients with BMI > 30 or those with BMI > 27 with obesity-related risk factors Nonetheless, use of medications has decreased in the United States since dexfenfluramine and fenfluramine were withdrawn from the market in 1997 after multiple reports of medication-associated valvular heart disease Although studies have since estimated the risk of valvular heart disease to be substantially less than the 30% prevalence first reported, this experience has led to considerable caution in the use of anorectic medications Anorectic medications can be classified as catecholaminergic or serotonergic Catecholaminergic medications include amphetamines (with high abuse potential) and the nonamphetamine schedule IV appetite suppressants phentermine, diethylpropion, and mazindol The selective serotonin reuptake inhibitor (SSRI) antidepressants, eg, fluoxetine and sertraline, have serotonergic activity but are not approved by the Food and Drug Administration (FDA) for weight loss Several medications remain available for treatment of obesity Older catecholaminergic medications (eg, phentermine, diethylpropion, mazindol) are approved for short-term use only and have limited utility Two newer medications are approved for weight loss: sibutramine and orlistat Sibutramine blocks uptake of both serotonin and norepinephrine in the central nervous system Orlistat reduces fat absorption in the gastrointestinal tract Sibutramine, typically at doses of 10 mg/d, results in average weight losses of 3 5 kg more than placebo in studies extending over 6 12 months Sibutramine also appears to improve 1-year outcomes in patients on very-low-calorie diets Side effects include dry mouth, anorexia, constipation, insomnia, and dizziness In some patients (< 5%), sibutramine may substantially increase blood pressure Orlistat is the first approved medication for obesity that works in the gastrointestinal tract rather than the central nervous system By inhibiting intestinal lipase, orlistat reduces fat absorption As expected, orlistat may result in diarrhea, gas, and cramping and perhaps also reduced absorption of fat-soluble vitamins In randomized trials with up to 2 years of follow-up, orlistat has resulted in 2 4 kg greater weight loss than placebo The recommended dose of orlistat is 120 mg three times daily with meals Despite FDA approval of sibutramine and orlistat and NIH guidelines
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Most successful programs employ a multidisciplinary approach to weight loss, with hypocaloric diets, behavior modification to change eating behavior, aerobic exercise, and social support Emphasis must be on maintenance of weight loss Dietary instructions for most patients incorporate the same principles that apply to healthy people who are not obese, ie, a low-fat, high-complex carbohydrate, high-fiber diet This is achieved by emphasizing intake of a wide variety of predominantly unprocessed foods Special attention is usually paid to limiting foods that provide large amounts of calories without other nutrients, ie, fat, sucrose, and alcohol There is no special advantage to diets that restrict carbohydrates, advocate relatively larger amounts of protein or fats, or recommend ingestion of foods one at a time In some instances, however, diets that are restricted in carbohydrates can be effective in achieving a lower total calorie intake Several studies have demonstrated that low-carbohydrate diets can be used safely for weight loss for up to 1 year without adverse effects on lipids or other metabolic parameters Meal replacement diets can also be used effectively and safely to achieve weight loss Long-term changes in eating behavior are required to maintain weight loss Although formal behavior modification programs are available to which patients can be referred, the clinician caring for obese patients can teach a number of useful behavioral techniques The most important technique is to emphasize planning and record keeping Patients can be taught to plan menus and exercise sessions and to record their actual behavior Record keeping not only aids in behavioral change, but also helps the provider to make specific suggestions for problem solving Patients can be taught to recognize eating cues (emotional, situational, etc) and how to avoid or control them Reward systems and refundable financial contracts are also useful for many patients Regular self-monitoring of weight is also associated with improved long-term weight maintenance Exercise offers a number of advantages to patients trying to lose weight and keep it off Aerobic exercise directly increases the daily energy expenditure and is particularly useful for long-term weight maintenance Exercise will also preserve lean body mass and partially prevent the decrease in basal energy expenditure (BEE) seen with semistarvation When compared with no treatment, exercise alone results in small amounts of weight loss Exercise plus diet results in greater weight loss than diet alone A greater intensity of exercise is associated with a greater amount of weight loss Up to 1 hour of moderate exercise per day is associated with longterm weight maintenance in individuals who have successfully lost weight Social support is essential for a successful weight loss program Continued close contact with clinicians and involvement of the family and peer group are useful techniques for reinforcing behavioral change and preventing social isolation Patients with severe obesity may require more aggressive treatment regimens Very-low-calorie diets ( 800 kcal/d) result in rapid weight loss and marked initial improvement in obesity-related metabolic complications Patients are commonly maintained on such programs for 4 6 months and lose an average of 2 lb per week Average weight loss is approxi-
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