A Vertically Integrated System for Managing Obesity David Heber, M.D., Ph.D.

A Vertically Integrated System for Managing Obesity

David Heber, M.D., Ph.D.

Introduction

Obesity is a complex multifactorial chronic disease that develops from an interaction of genetics and environment. Genotype determines the potential for obesity, but environment including diet and lifestyle determines whether and to what extent that potential is realized. Our understanding of how and why obesity develops is incomplete, but involves an integration of social, behavioral, cultural, physiological, metabolic and genetic factors. The NIH Expert Panel on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults reviewed the published literature between January 1980 and September 1997. Evidence from 394 randomized controlled trials was reviewed by the 24 member panel. The keystone of the evaluation and treatment guidelines issued in June 1998 is the application of the body mass index (BMI) and waist circumference to classify obese patients as follows:

BMI (kg/M2) Obesity Class Risk of HTN, DM. CAD

Waist Circ. Waist Circ.

< 40" in men > 40" in men

< 35" in women > 35" in women

Underweight < 18.5

Normal 18.5 - 24.9

Overweight 25.0 - 29.9 Increased High

Obesity 30.0 - 34.9 I High Very High

35.0 - 39.9 II Very High Very High

Extreme Obesity > 40 III Extremely High Extremely High

Here are some of the points supported by an evaluation of the data available from the report: (Categories of evidence: A=RCT Evidence; B= Limited No. RCT'S; C.- Uncontrolled Trials; D= Expert Judgement of Panelists) All conclusions based on A or B categories only.

Low Calorie Diets(LCD's) > 800 Calories per day with both reduction in fat and a calorie target are recommended for weight loss. Low fat diets without calorie targets are not as effective. Very Low Calorie Diets (VLCD) 400 to 550 Calories per day provide more initial weight loss but are no more effective at one year. A diet that is individually planned to create a deficit of 500 to I 000 Calories per day should be an integral part of any program aimed at a weight loss of I to 2 pounds per week. 86 RCT's reviewed: Category of evidence = A)

Physical Activity is recommended because a) it modestly contributes to weight loss (category A); b) may decrease abdominal fat (category B); and c) increases cardiorespiratory fitness (category A). Moderate levels of physical activity for 30 to 45 minutes 3 to 5 days per week should be encouraged initially with an ultimate goal of at least 30 minutes of physical activity per day (evidence category B).

Behavior therapy is a useful adjunct when incorporated into treatment for weight loss and weight maintenance (category B). Weight loss and weight maintenance therapy should employ the combination of LCD's, increased physical activity, and behavior therapy. (category A)

Weight loss drugs approved by the FDA may be used as part of a comprehensive weight loss program including dietary therapy and physical activity for patients with a BMI of > 30 with no concomitant obesity related risk factors or diseases, and for patients with a BMI of > 2 7 with concomitant obesity-related risk factors or diseases. Weight loss drugs should never be used without concomitant lifestyle modifications. Continual assessment of drug therapy for efficacy and safety is necessary. If the drug is efficacious in helping the patient to lose and/or maintain weight loss and there are no adverse serious adverse effects, it can be continued If not, it should be discontinued (Category B)

Weight loss surgery is an optionfor carefully selectedpatients with clinically severe obesity (BMI > 40 or > 35 with co-morbid conditions) when less invasive methods of weight loss havefailed and the patient is at high riskfor obesity-associated morbidity or mortality (Evidence Category B).

POINTS TO REMEMBER IN OBESITY MANAGEMENT

Physician as "Agent of Change"

Vertically Integrated System Using Diet, Exercise, and Lifestyle Change

Treatment of Co-Morbid Medical Conditions

Treatment of Psychological Conditions

Adjunctive Use of Pharmacotherapy and Surgery in Appropriately Selected Patients

Follow-Up and Lifestyle Change

1. Physician as "Agent of Change" 

As primary care physicians step up to become the "agents of change" for their patients, it will be important to economize time and effort while conveying to the patient the key emotions of empathy and positive encouragement. When you master this vertically integrated approach, you will be preventing and treating common problems such as diabetes mellitus, hypertension, and hyperlipidemias from a very different perspective than you were taught in medical school through the use of nutritional management. The goal is not weight loss to some unattainable ideal weight, but rather the goal is a sustainable reduction of 5 to 15% in body weight maintained over the long-term using diet, exercise and lifestyle change as aided by phamacotherapy or surgery in properly selected patients.

IDENTIFYING THE CHIEF COMPLAINT AND CO-MORBID CONDITIONS 

When a patient comes in for a visit, the vital signs include a height and weight, the chart may include a list of potential co-morbid conditions, and the patient may have been given an opportunity to express their readiness to change. This set of data permits the first objective assessment that can keep obesity from being an invisible disorder.

ASSESSING MOTIVATION TO UNDERTAKE LIFESTYLE CHANGE

A simple question on a patient entry form such as "Would you like to lose weight ?" and some indication of how high a priority this concern has for the patient is one way for patients to identify to the physician that they are interested in weight loss and ready to change. It is clear that this is one of the ma or factors involved in whether the patient will be successful. If the patient does not take ownership of the problem, then you will not be successful in lifestyle change. One of the most common reasons for patients not having motivation to change are psychological problems including depression and co-dependency. If these are identified they must be treated as well (see below).

NUTRITION EDUCATION/BEHAVIORS:REDUCE TRIGGER FOODS, USE MEAI, REPLACEMENTS AND PORTION-CONTROLLED FOODS 

The initial message in smoking cessation is simple: STOP SMOKING!. In nutrition education by the physician the initial nutrition/behavior message is the elimination of trigger foods. THESE ARE NOT DIETARY GUIDELINES AND THERE IS NO NEED FOR THEM TO CONFORM TO NCEP, ADA, AHA OR OTHER GUIDELINES FOR THE GENERAL PUBLIC. YOU NEED TO DEVELOP TARGETED ADVICE FOR AN OBESE PATIENT THAT IS TAILORED INDIVIDUALLY. THE FOLLOWING CAN BE MODIFIED AND IS GIVEN AS AN EXAMTLE USED IN MY PRACTICE. 

The Messages Below in quotes are Nutrition/Behavior Scripts you can modify for your own practice or use "as is" with your patients. Experiment to develop your own style, and believe in what you counsel. Nothing is more powerful than telling a patient "I'm not asking you to do anything I wouldn't do in my own diet." 

Here is the Script:

"Minimize the following especially if they are trigger foods for you: 

Nuts: (including almonds, walnuts, pistachios, and other tree nuts not peanuts): Nuts and seeds are sources of protein, fiber, vitamins, minerals, and antioxidants. However, they are a rich source of calories, so eat only about 8 almonds, pistachios or other tree nuts especially after exercise. Don't eat nuts as a trigger food,. Just 14 peanuts have 90 calories, and a peanut is not a nut -- it's a bean!!!

Cheese and Pizza: Hard Cheese has up to 80% fat, and even non-fat cheese is 80 calories per slice; Pizzas are made with oil in the crust, cheese on top, so the calories add up fast! Try zucchini, spaghetti squash or a high fiber whole wheat pasta with tomato sauce instead. 

Salad Dressing: Both creamy and oil-based salad dressings provide, on average, 150 calories and 10-20 grams of fat per ounce. So, avoid all dressings, including so-called low fat varieties. Try balsamic vinegar, rice vinegar, or wine vinegar instead. Make your salad tasty with dark green lettuce, tomatoes, alfalfa sprouts, green pepper, and other vegetables so that you don't depend on the dressing to carry the taste. 

Mayonnaise, Margarine and Butter: There is no daily margarine requirement. Even the fat-free varieties are 100% fat calories. According to the law, these can be labeled as fat-free because they have less than 0.5 grams of fat per serving. This is the only place in mathematics you can round down from 0.5 to 0. Try having high fiber bread dry with just a thin layer of fruit jam, or if you are having a sandwich, use mustard or ketchup instead of mayonnaise.

Red Meat and Fatty Fish: One of the easiest places to reduce a lot of calories is red meat and fatty fish.

Red meat (veal, beef, pork, and lamb) Yes - Pork is not the other white meat! Red meats are higher in total fat and cholesterol than poultry breast. One 14 ounce cut of prime rib has about 1500 calories and 50 grams of fat! That's all the fat and calories many women need all day long. Substitute skinless white meat of chicken or white meat of turkey for read meat. If it will help, put steak sauce on chicken and pretend it's red meat. Dark poultry meat is higher in fat than white meat and can have as much fat as some types of red meat.

Salmon, trout, and catfish that are farm-fed are high in total fat. While the content of so-called "good fat" is similar in farmed and ocean-caught salmon, the farmed variety have twice as much "bad fat" in addition to the "good fat". They are the steak of the fish world with over 800 calories in an 8 ounce serving. Substitute halibut, cod, sole, canned white tuna packed in water, orange roughy, red snapper, or Hawaiian fish.. Shrimp, scallops, lobster, and crab are also low in fat. Avoid the small bay shrimp, swordfish, and other scavenger fish which are high in mercury.

Beans, Rice, Potatoes, Pasta, Crackers, Chips and Breads: While you may think these foods are healthy, you need to know that a cup of rice, beans, pasta, or potatoes have 250 Calories compared to only 40 calories or less for a cup of most vegetables. Order a double portion of vegetables in the restaurant and skip the mashed potatoes or rice on your dinner plate. It's an easy way to cut out over 200 calories. Don't order chips or bread to the table before your meal. You may be eating 550 Calories in a basket of chips or 320 Calories in a bagel or several slices of bread. Have only one slice of high fiber bread which has 7 grams of fiber in 70 calories and you will get full faster, or skip the bread altogether. You need only three servings per day of high fiber whole grain foods. Read the label carefully, there are no label standards for 'whole grain'.

Frozen Yogurt, Ice Cream, Cakes, and Pastries: These desserts add lots of extra calories from fat and sugar. Even the fat-free versions pack in many extra calories because they are loaded with sugar and can be loaded with calories. Instead, have a piece of fruit, or you can drizzle some chocolate syrup on sweet strawberries, bananas, pineapple or other fruit to satisfy your sweet tooth.

Colas and Juices: A can of cola or soda has 150 Calories a Big Drink has over 600! Have plain water or mineral water with a slice of lemon or lime. Have a fruit instead of fruit juices or flavor water with small amounts of 100% juice.

Counsel Stepwise Gradual Change for Tough Trigger Foods Here are some messages I use to soften the impact. "Make each one of these a goal to work towards. It's a much different matter to drift away from these strict guidelines than to adopt guidelines that encourage margarine instead of butter. Look, at least you will always know when you are on or off the above diet without having to fill out a food record. You will get great results if you do this 80 or 90 percent of the time. You don't have to be a fanatic."

Counsel Meal Replacement, Portion-Control and Simplicity for the Initial Approach to Diet You can customize and adjust the message below as you see fit for your opinions and practice: "Breakfast: Try a high protein meal replacement shake made with a soy/whey protein powder plus 1 cup of nonfat milk or soy milk and a cup of berries. The protein in the shake will keep your hunger at bay all morning. Other high protein breakfast options could be a cup of plain yogurt or cottage cheese or 6-7 scrambled egg whites with some fruit. Lunch: Try another meal replacement shake (as at breakfast). Or, have a large mixed green salad with 3-6 ounces of lean protein (chicken breast, turkey breast, shrimp, flaked tuna or a cut up grilled soy patty) on top with balsamic vinegar or rice vinegar and seasonings. Have some fruit for dessert. If your calories allow, you can have an open-face sandwich made with 1 slice 100% whole grain bread, with the protein on top and a mixed salad on the side. Late Afternoon Snack: A protein snack in the afternoon will keep you from getting too hungry at dinner. Try a small protein bar or half of a large bar, or some soy nuts, or a cup of cottage cheese or plain yogurt. You can have some fruit or vegetables, or tomato juice or vegetable juice with your snack. Dinner: Dinner is similar to lunch with protein and a tossed salad. Add 2 cups of steamed vegetables and fruit for dessert. If your calories allow, you can have a small portion of starch or grain, such as ½ cup brown rice or ½ small baked sweet potato.

This nutrition/behaviors message takes a few minutes to give and can be delegated in part to allied health personnel, but it must be developed and rehearsed TO BE CONSISTENT as it is the key message to be reinforced by the patient's self-education, other health messages and the counseling of nutritionists and other health professionals. This runs counter to variety, moderation, and balance which only make sense in a society where the diet is basically healthy. Basic physiology supports the fact that variety promotes overeating, whereas sensory-specific satiety is promoted by routine behaviors in obese patients. In our society, cultivate a healthy dissatisfaction with the status quo in your obese patients.

2. Vertically Integrated System Using Diet, Exercise, and Lifestyle Change

DOES THE PATIENT HAVE MEDICALLY SIGNIFICANT OBESITY? 

Check BMI table or calculate weight in kg divided by height( in meters) squared. or multiply weight in pounds by 705 and divided by height in inches squared (on a simple calculator this simply means repeating the division operation twice). BMI is the standard for clinical guidelines designed to select among treatment modalities.

In general:

BMI 20 to 25 normal : diet, exercise and lifestyle change

25 to 30 : diet, exercise and lifestyle change (DEL)

27 to 30: DEL + pharmacotherapy if co-morbidity(see below)

30 to 40: DEL + pharmacotherapy

35 to 40: DEL + pharmacotherapy or surgery (if co-morbidity)

> 40: DEL + pharmacotherapy or surgery 

3.Treatment of Co-Morbid Medical Conditions 

The co-morbidities identified in the initial contact with the patient require independent management which parallels the management of the primary underlying problem of obesity which is promoting and maintaining the co-morbid condition.

Diabesity vs. so-called Diabetes Mellitus Type II (NIDDM) Diabetes mellitus (sweet urine) is the tip of the iceberg of a genetic-environmental condition characterized by obesity in greater than 80% of all patients. Recently, the criteria for diagnosis have been changed from a fasting blood sugar of >140 mg/dl to >126 mg/dl. The standard medical approach to the diabetic is to make the diagnosis of the disease and send the patient to a nurse to learn glucose monitoring, to a dietitian to be taught an exchange diet, and to a pharmacist to receive pharmacotherapy (oral agents or insulin) for their diabetes. Throughout this process there has been no consideration of the primacy of hyperinsulinemia due to excess visceral/abdominal fat. In the nutritional medicine approach, if there is no infection present or surgery planned, then glucose control must be secondary to the attempts to lose visceral fat and increase muscle mass. In fact, over 80% of all patients receiving insulin never attain normal blood glucose levels. Moreover, both insulin and oral agents increase appetite leading to weight gain and undercutting attempts at weight management. Minimize or discontinue hypoglycemic treatment during periods when the patient is attempting to lose weight. 

Hypertension: Mild vs. Uncontrollable The majority of hypertensive patients have mild hypertension with a diastolic blood pressure of 90 to 95 mm Hg. According to all the stepcare approaches endorsed by medical organizations diet, exercise, and lifestyle change are the first steps in treatment. However, the standard medical treatment is to use an antihypertensive such as an ACE inhibitor. In fact, many patients with mild obesity-associated hypertension will normalize in the first two weeks of obesity treatment. The first weight loss is due in large part to urinary losses of water and sodium chloride (2 lb./quart). The amount can be estimated from extrapolating backwards from the rate of true fat and lean loss after the initial diuresis. Insulin levels decrease rapidly with calorie restriction and this accounts for the loss of water since insulin is a sodium-retaining hormone. Some appetite suppressants will raise blood pressure slightly so the initial weight loss is important in making these safe in the mildly hypertensive patient. For patients with more significant hypertension continue the treatment with antihypertensive agents even in combination to control blood pressure. As the patient loses weight, these can be tapered slowly and ultimately discontinued in some patients. However, it should be remembered that hypertension returns with weight gain, so that the reduction and discontinuation should be done conservatively in some patients with a strong message indicating the relationship of blood pressure and weight gain. For patients with uncontrollable hypertension, this becomes the main problem even with the recognition that many antihypertensive agents cause negative side effects which may impair weight loss. Fortunately, this should be a small fraction of the patients you see. 

Hyperlipidemia, Hypercholesterolemia, Dyslipidemia There are about 37 million people with Total Cholesterol > 240 mg/dl where drugs to lower cholesterol are approved for use. Only 3 to 4 million people are currently being treated. There are 58 million people with Total Cholesterol of 200 to 240 mg/dl who should receive dietary counseling and natural remedies for cholesterol reduction. However, the NCEP diet is not effective in lowering cholesterol as it continues to include obesity-promoting food choices such as low fat and non-fat margarine, low fat salad dressings, non-fat yogurt, nuts, non-fat cheese, and it does not consider meal replacements or portion controlled-foods (see trigger foods above). Weight loss is particularly effective for dyslipidemia (borderline high cholesterol, borderline high triglycerides, and low HDL cholesterol).

Physical Complaints, Low Back Pain, Arthritis. Refer to a physical therapist as a step towards instituting a regular exercise program for low back pain or other complaints. For patients with less severe disability refer to trainer for a stretching program with aerobic and some dumbbell exercises. Give Exercise Prescriptions if you can. 

4. Treatment of Psychological Conditions Patients with chronic depression or codependency require referral to outside resources. Stress and Bum-Out or Atypical Depression are closely related to overeating and binge-eating. Use SSRI's in appropriate patients and consider effects of appetite suppressants on mood.

5. Use of Pharmacotherapy and Surgery in Appropriately Selected Patients The key here is to write a prescription or advise surgery only in patients willing to follow a diet. Repeat that there is no single cure. Patients must change lifestyle to be able to take advantage of these approaches. See rationale for details of doses and type of surgery.

6. Follow-Up and Lifestyle Change Lifestyle change must be permanent. As an agent of change the physician must provide biweekly visits the first month, five monthly visits then periodic visits thereafter at not less than six month intervals. Interim weekly to monthly visits can involve classes or outside groups, but the physician must be aware of the material being provided. Standard behavioral approaches include self-monitoring, social support, stress reduction, and stimulus control. These concepts are all included in the nutrition/behavior messages above and are seamlessly integrated by the physician as the agent of change as well as the long-term monitor of maintenance and relapse prevention.

REFERENCES 

Frank A. Futility and avoidance: medical professionals in the treatment of obesity. JAMA 1993;269:2132-2133.

A concise and cutting statement of the dilemmas facing physicians treating obesity. 

Institute of Medicine. Weighing the Options. Criteria for evaluating weight management programs. Washington DC, Government Printing Office, 1995. An excellent text for background reading on obesity. Includes a readiness to change questionnaire which can be used and emphasizes tailored approaches. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. The Evidence Report. National Institutes of Health NHLBI, Bethesda, 1998.

Heber D. with Bowerman S. The L.A. Shape Diet. New York: Regan Books/Harper Collins. 2004.

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