The article below comes from the November 1, 2003 edition of “OB GYN News” , page 26

An estimated 127 million adults in the United States are overweight, 60 million are obese, and 9 million are severely obese, according to national statistics.

And yet, studies show that obesity remains an undertreated condition. Many physicians are uncomfortable discussing it with overweight patients, and some view it as a disease of morality – patients are at fault because they have no self-control. And because these patients require a consistent, long-term program of lifestyle modification, perhaps with pharmacotherapy as well, many primary care providers don’t have the time or skills to manage them.

Assessment

OB/GYN’s should record body mass index (BMI) at each patient visit. The BMI shows relative weight for height and correlates significantly with body fat content. It may not be completely accurate for some women who exercise heavily and have an unusually high percentage of muscle.

In nonpregnant women, a BMI of 25-29 is considered overweight; 30 and above is considered obese. Abdominal waist circumference is another key indicator: A circumference of more than 35 inches in non-pregnant women significantly increases the relative risk of disease.

Management

One BMI unit is about 6 pounds, which most women can lose in less than a month. On the other hand, it will usually take at least 6 months to lose 10 percent of initial body weight. After 6 months, the rate of weight loss usually declines and additional weight reduction is even more difficult.

For these women, the initial goal of treatment is to reduce body weight by 10 percent from baseline. This can be accomplished by achieving a deficit of 500-1,000 calories per day while following a low-fat diet rich in fruits and vegetables and low-fat dairy products. The National Cholesterol Education Program’s Therapeutic Lifestyle Change diet plan limits fat intake to 25-30 percent of daily calories; this plan is availab le at the National Heart, Lung and Blood Institute Web site, nhlbi.nih.gov.

Many studies have shown that women achieve greater weight loss with group support than if they attempt to lose weight on their own. The Weight Watchers program is an example of a nutritionally sound plan that not only reduces caloric intake but includes behavior modification and group support, and teaches important weight management skills, such as portion control and how to read food product labels.

Exercise should be a component of every weight-loss plan, although studies show that exercise itself does not lead to substantially greater weight loss over 6 months; most comes from caloric restriction. Sustained physical activity is critical to maintaining weight loss and has myriad other health benefits.

Women who don’t currently exercise can start by walking 30 minutes, 3 days a week, building to 45 minutes of more intense walking 5 days a week. This regimen will result in an additional deficit of 100-200 calories per day.

A combined regimen of behavioral therapy, caloric restriction, and physical activity will yield the best results, but it takes time. This combination should be followed for at least 6 months before considering pharmacotherapy.

Patients who initiate pharmacotherapy usually lose 5-10 percent of their baseline weight; most drugs work by suppressing appetite, while some increase metabolism. But some of these drugs carry the risk of increased blood pressure and heart rate, and patients taking them should have their blood pressure monitored. The drugs shouldn’t be prescribed to women with a history of heart disease, congestive heart failure, irregular heartbeat or stroke. Orlistat, a lipase inhibitor, decreases dietary fat absorption by 30 percent. Its main adverse effects are gastrointestinal, and include diarrhea, flatulence, cramps and stool leakage.

Over-the-counter weight-loss preparations are not standardized in terms of dosage and can be dangerous. Ephedra and ma huang increase metabolism and can lead to serious cardiovascular events. Chitosan, a shellfish extract, has been marketed as a “fat binder,” but numerous clinical studies have shown that it did not cause clinically meaningful malabsorption of fat.

Gastric bypass and gastric banding are highly effective measures for selected patients who are morbidly obese. However, the surgery is expensive and may not be covered by insurance.

 

– Michele G. Sullivan

Source: Dr. Judith S. Stern, professor of nutrition and internal medicine, University of California, Davis, and vice president of the American Obesity Association

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