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American Dietetic Assoication’s position on weight management
Tuesday, May 11, 2004 1:13 pm Email this article
Here is the American Dietetic Assoication's position on weight management as of 2002.
OBESITY-RELATED COSTS: $70 BILLION PER YEAR
Obesity-related health care costs total $70 billion per year in the U.S. (p. 1145, col. 2).
LIFESTYLE CHANGES: 3-6 PERCENT WEIGHT LOSS
Studies have shown that weight loss from changes in lifestyle are typically about 3 to 6 percent of body weight after 4 to 5 years.
5 PERCENT WEIGHT LOSS BENEFICIAL
A weight loss of 5 percent has health benefits and counters weight gain that would have happened otherwise.
GOAL SHOULD BE TO REDUCE RISKS
“We must move away from assuming that weight management is synonymous with the achievement of slenderness… [P]atients must be helped to acheive and accept a healtheir weight and adopt healtheir lifesyles that lead to reducing health risks.” (p. 1146, col. 1)
GENES ACCOUNT FOR 60-80 PERCENT OF PREDISPOSITION
Genetic factors account for 60 to 80 percent of the predisposition to obesity. (p. 1146, col. 1)
“Nearly all individuals with obesity exhibit an excess of circulating leptin in direct proportion to their body mass index. Thus human obesity appears to result from functional resistance to the effects of leptin, much as type 2 diabetes reflects resistance to the physiological effects of insulin.” (p. 1146, col. 2 top)
SEVERAL DOZEN GENES INVOLVED
“There are at least several dozen genes involved in obesity, and not only does current weight status have an inherited component, but the metabolic processes underlying weight gain may have strong genetic influences.” (p. 1146, col. 2)
GENETIC INVOLVEMENT MAY VARY BY RACE
The genetic contribution to our body weight may vary by race. This may become more apparent as the ethnic makeup of the United States changes.
61 PERCENT OVERWEIGHT
As of 1999, 61 percent of American were overweight.
PORTION SIZE HAS INCREASED
Part of the obesity epidemic is due to an increase in portion size. (p. 1146, col. 2)
Another contributing factor is calorie dense foods such as those found at fast food restaurants and convenience foods.
DRUGS ASSOCIATED WITH WEIGHT GAIN
Drugs that are associated with weight gain include antipsychotics, antidepressants, mood stabilizers, and to a lesser degree, anxiolytics (a tranquilizer used to relieve anxiety).
Drugs that block histamine H1 receptors, dopamine receptors, and serotonin receptors, cause weight gain.
MOOD STABILIZERS: LITHIUM, DEPAKOTE, TEGRETOL
Weight gain is also commonly reported with mood stabilizers such as lithium and anticonvulsants including valproic acid (Depakene; Depakote) and carbamazepine (Atretol; Depitol; Epitol; Tegretol).
Alternative choices are available, and a newer medication, topiramate (Topamax), has been associated with mild, dose-related weight loss.
OTHER DRUGS ASSOCIATED WITH WEIGHT GAIN
“Other medications that also may cause weight gain include steroids, cyproheptadine [Periactin], and insulin.” (p. 1147, col. 1)
PSYCHOLOGICAL STATES ASSOCIATED WITH WEIGHT GAIN
Some patients lose weight when they become depressed, while others gain weight. This tends to repeat itself with each depression.
Since serotonin is involved in both controlling mood and can be affected by eating, some patients learn they can relieve their depression temporarily by eating.
SAD, PMS, AND NICOTINE WITHDRAWAL
This is seen frequently in patients with seasonal affective disorder (SAD), premenstrual syndrome (PMS), and nicotine withdrawal. (p. 1147, col. 1)
“Waist circumference is most useful when BMI is less than 35 and is more predictive of illness risk than BMI after age 65 and in Asian-American populations.” (p. 1148, col. 1)
WAIST: MEN LESS THAN 40 INCHES, WOMEN 35 INCHES
High risk is associated in men with a waist circumference greater than 40 inches and in women with a waist circumference greater than 35 inches. (p. 1148, col. 1)
4 CATEGORIES OF WEIGHT-RELATED PROBLEMS
“Weight-related complications may be divided into 4 categories:
“a) metabolic complications (diabetes, hypertension, high cholesterol, gallstones, reproductive dysfunction, thromboembolic disease);
“b) anatomic complications (obstructive sleep apnea, reflux disease, venous insufficiency, stress incontinence, injuries);
“c) degenerative complications (arthritis, disc disease, atherosclerotic disease, pulmonary hypertension) , and
“d) neoplastic complications (colorectal, esophageal, adenocarcinoma, endometrial, breast, prostate, ovarian).” (p. 1148, col. 1)
TEAM APPROACH RECOMMENDED
“For effective weight management treatment, the client should be assessed by a multidisciplinary team, including a physician, registered dietitian, exercise physiologist, and a behavioral therapist.” (p. 1148, col. 2)
GOALS: DOCTOR AND PATIENT SHOULD AGREE UPON
At the onset of treatment the physician and the patient should agree upon goals. (p. 1148, col. 2)
DEVELOP SHARED RESPONSIBILITY
“The clinician needs to avoid overpowering advice inferring ‘do as I say’ versus empowering advice such as ‘pay attention to what you want to do; trust yourself in this process.’” (p. 1148, col. 2)
“With such an attitude the provider and the patient will develop a relationship of shared responsibility.” (p. 1148, col. 2)
Losing 10 percent of body weight can reduce the health risks associated with excess body weight.
DIET FOR MAINTAINING WEIGHT LOSS
People on a moderate fat, high-carbohydrate diet as recommended by the Food Pyramid Guide were more likely to maintain weight loss according to data from the Continuing Survey of Food Intakes by Individuals 1994-1996. (p. 1149, col. 2)
VERY LOW CALORIE DIETS: POOR LONG-TERM MAINTENANCE
“Data regarding severe energy restricted diets, such as very low calorie diets (VLCDs), show that despite the short-term success of achieving significant weight losses, there is poor long-term maintenance of losses.” (p. 1149, col. 2)
LOW CALORIE DIETS: 8-10 PERCENT LOSS
Low calorie diets can cause a weight loss of 8 to 10 percent in six to twelve months. However, most people regain their weight. (p. 1149, col. 2)
“Diets can be classified as: starvation (0-200 kcals/ day); very-low calorie (200-800 kcals/day) or low calorie (>800 kcal/day).” (p. 1150, col. 1)
“Starvation diets include fasting, which has been used for centuries and results in a loss of lean body mass and mineral loss due to diuresis.” (p. 1150, col. 1)
VERY LOW CALORIE DIETS (VLCD)
“VLCDs are protein-sparing modified fasts using either a premixed liquid or meat, fish, or poultry… [T]hey are [usually] reserved for patients who have BMIs greater than 30 and have failed other approaches.” (p. 1150, col. 1)
“Patients should be under medical supervision and must receive supplemental vitamins and minerals.” (p. 1150, col. 1)
WEIGHT LOSS NOT GREATER OVER TIME WITH VLCD
“Weight losses over time are not greater than a mixed diet of equal caloric content, and the resumption of eating solid foods frequently disrupts maintenance efforts.” (p. 1150, col. 1)
LOW CALORIE DIETS
A diet containing 500-1000 calories per day less than a person needs should cause a weight loss of 1-2 pounds per week. (p. 1150, col. 1)
“Meal replacements are another category of calorie-controlled diets. Individuals replace a meal with a liquid drink that contains approximately 200 calories per serving and approximately 50% to 60% carbohydrate, 30% protein, and 10% fat or a pre-measured frozen meals of a set caloric value.”
“The replacements help keep calories under control and probably, more importantly, reduce sensory stimulation and the need to make decisions about portion size.”
MEAL REPLACEMENTS: 3-8 PERCENT LOSS FOR FOUR YEARS
Studies using meal replacements have acheived weight losses of 3.2% to 8.4% over four years. (p. 1150, col. 1)
U.S. WEIGHT LOSS INDUSTRY $30 BILLION PER YEAR
The weight loss industry in the U.S. exceeds $30 billion per year.
Another reason for the obesity epidemic is lack of physical activity. (p. 1150, col. 2)
REGULAR EXERCISE PREDICTS WEIGHT MAINTENANCE
“Regular physical activity also appears to be one of the best predictors of successful weight maintenance.” (p. 1150, col. 2)
EXERCISE LIMITS LOSS OF LEAN BODY MASS TO 10 PERCENT
“The addition of moderate physical activity to restriction of energy intake in promoting weight loss, has been shown to limit the loss of lean body mass to less than 10%.” (p. 1150, col. 2)
Weight lifting in addition to aerobic exercise improves body composition. (p. 1150, col. 2)
BELLY FAT STRONGER RISK FACTOR FOR DISEASE THAN OVERALL FAT
“Although an increase in overall body fat is considered a risk for chronic disease, an increase in visceral abdominal fat has been identified as even a stronger independent risk factor for the development of type 2 diabetes, coronary heart disease, hypertension and some cancers than general obesity.” (p. 1150, col. 2)
WEIGHT LOSS AND EXERCISE REDUCE RISK FACTORS
“Weight loss and exercise together reduce total cholesterol, low-density cholesterol, triglyceride, plasma insulin, and blood glucose levels thereby reducing the risks for metabolic syndrome, type 2 diabetes, and heart disease.” (p. 1150, col. 2)
Regular exercise and improved cardiorespiratory fitness reduces the risk of death and disease, even when without weight loss. (p. 1150, col. 2)
“Currently there are few pharmacotherapy options available for long term usage.” (p. 1151, col. 1)
“Medications that have been approved by the FDA for treatment of “clinically significant” obesity (BMI greater than 30 or BMI 27-29 with one or more obesity-related disorders), include sibutramine [Meridia] and orlistat [Xenical].” (p. 1151, col. 1)
“Sibutramine (Meridia) is a centrally acting serotonin and adrenergic reuptake inhibitor.
MERIDIA SIDE EFFECTS
“It has the potential complication of hypertension and increased heart rate.” (p. 1151, col. 1)
“Orlistat (Xenical) is a pancreatic lipase inhibitor which inhibits the absorption of up to 30% of dietary fat.” (p. 1151, col. 1)
XENICAL SIDE EFFECTS
“Steatorrhea [greasy stool], bloating and distension, and anal leakage are potential complications, and one must be alert for possible fat-soluble vitamin deficiencies.” (p. 1151, col. 1)
WEIGHT LOSS WITH MERIDIA OR XENICAL: 4-22 LBS
“Reported losses with these medications combined with a low-calorie diet average [4-22 pounds] per year, and if the medications are discontinued weight gain results.” (p. 1151, col. 1)
PHENTERMINE, PHENDIMETRAZINE, ETC FOR SHORT-TERM USE
“Amphetamine-like derivitives: mazindol, phentermine, benzphetamine, phendimetrazine are available only for short-term use.” (p. 1151, col. 1)
HERBAL WEIGHT LOSS FORMULAS: HARMFUL EFFECTS
“The herbal preparations for weight loss do not have standardized amounts of active ingredients and have been reported to have harmful effects.” (p. 1151, col. 1)
PPA: NO PROVEN EFFICACY AND TIED TO HEMORRHAGIC STROKE
“Certain over-the-counter preparations containing propanolamine (Dexatrim and related compounds) have no proven efficacy for short- or long-term weight loss and are being recalled because of the incidence of hemorrhagic stroke.” (p. 1151, col. 1)
FDA PREVIOUSLY FOUND PPA SAFE AND EFFECTIVE
Note from Larry Hobbs: It is interesting that they say this because on several prior occassions the FDA reviewed the evidence for PPA and said that it was both safe and effective.
NOTE FROM LARRY HOBBS: FDA BAN OF PPA BASED ON A FLAWED STUDY
Note from Larry Hobbs: I also strongly disagree with the FDA’s conclusion that PPA increases the risk of hemorrhagic stroke.
Having spent months reviewing the study on which the FDA based their decision to ban PPA— the Yale Hemorrhagic Stroke study—and reading an additonal 300 papers and a couple of books related to PPA and hemorrhagic stroke, I was able to identify approximately 60 problems with the Yale study.
Some of these problems were enough to negate the findings of the study.
Unfortunately, the FDA ignored these problems, and even lied about one of the findings, in order to justify their ban.
Considering that for years the FDA said that PPA was both safe and effective, only to recently change their mind, I believe that the FDA banned PPA for the benefit of the pharmaceutical industry.
This also seems to be the case with the FDA trying to stop people from importing drugs from Canada saying that these drugs might be dangerous.
On March 14, 2004, in a segment called “Prescriptions and Profits” on the television program “Sixty Minutes” they reported that for the last year the head of the FDA, Mark McClellan, has been waging a war against the importation of drugs from Canada.
The FDA has even posted warnings saying “The medicine you buy across the border may be unsafe or ineffective. Don’t risk your health.”
However, on the same program Dr. Marsha Angel, who was Executive Editor of the New England Journal of Medicine for 11 years and who is writing a book on the secrets of the pharmaceutical industry, said, “That’s a lot of hooey [nonsense]. There is no reason that buying drugs in Canada is any less safe than buying them here.”
It is worth noting that the head of the FDA is Mark McClellan, M.D., Ph.D., served in the White House in 2001 and 2002 under President Bush as a Member of the President’s Council of Economic Advisers, where he advised on domestic economic issues. He also served during this time as a senior policy director for health care and related economic issues for the White House.
It should also be noted that Mark McClellan is the brother of President Bush’s White House Press Secretary, Scott McClellan.
I see Mark McClellan’s association to the White House as a conflict of interest.
I worry that as head of the FDA, Dr. McClellan may have made decisions based on what was good for President Bush politically, rather than what was good for the American people.
I believe that the decision to ban ephedra was also politically motivated.
Back to the summary of the paper at hand.
EPHEDRINE AND CAFFEINE, AND PROZAC NOT APPROVED FOR WEIGHT LOSS
“Ephedrine plus caffeine, and fluoxetine have been tested for weight loss, but not approved and over-the-counter and herbal preparations are currently not recommended (92).
“Pharmacotherapy research is currently focusing on three approaches,
“a) inhibitors of energy intake (appetite suppressants, orexins/hypocretin antagonists);
“b) enhancers of energy expenditure, UCP2 and UCP3 uncoupling proteins; and
“c) stimulators of fat mobilization.” (p. 1151, col. 1)
WEIGHT LOSS SURGERY
Gastric surgery is the most effective approach for generating long-term weight loss in extremely heavy people.
20-25 PERCENT WEIGHT LOSS
“More than 90% of patients experience significant (greater than 20% to 25%) weight loss, and between 50% and 80% maintain weight loss for over 5 years; in contrast, the 5-year efficacy of other approaches is approximately 5%.” (p. 1151, col. 1)
1-3 PERCENT RISK OF DEATH FROM SURGERY
Gastric surgery carries a 1 to 2.5 percent risk of death.
“Accepted indications for surgical weight loss therapy are having a BMI greater than 40 or BMI 35-39 with one or more obesity-related disorders; and having previously unsuccessful non-surgical attempts at long-term weight management.” (p. 1151, col. 2)
LIPOSUCTION NOT FOR THE PURPOSE OF WEIGHT LOSS
Liposuction is not for the purpuse of weight loss. (p. 1151, col. 2)
SUCCESSFUL WEIGHT LOSS: 5 PERCENT OR 14 POUNDS
“A successful program is often defined as one that produces maintenance of loss of at least 5%, or [14.5 pounds]??of body weight.” (p. 1151, col. 2)
“[Weight] Regain should not be framed as a personal failure but rather as an indication of a need for another phase of active management.” (p. 1152, col. 1)
Cummings S, Parham E, Strain G. Position of the American Dietetic Association: weight management. J Am Diet Assoc. 2002 Aug, 102(8):1145-55.
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