General Approach to Treatment

Since the goals for obesity management in the adult population are multifactorial, it should be considered a chronic illness where treatment is maintained for life. Any implemented therapy promoting weight loss should focus on behavior modification directed toward both dietary restriction and increased activity in conjunction with the selective use of pharmacologic or surgical intervention. Before initiating therapy, secondary causes of obesity (e.g., hypothyroidism and Cushing syndrome) must be considered. Current treatment with medications that negatively alter weight should be determined and if present, alternative therapies should be suggested. Table 102-4 provides a list of drugs commonly associated with weight gain. If no secondary cause exists, the presence of other cardiovascular risk factors and comorbidities must be determined to guide clinical decisions. Presence of comorbidities (CHD, atherosclerosis, type 2 diabetes mellitus, and sleep apnea) and cardiovascular risk factors (cigarette smoking, hypertension, elevated low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, impaired fasting glucose, family history of premature CHD, and age) requires identification and aggressive management for overall effective treatment of the overweight or obese patient. Therapy implemented to minimize associated risk(s) may not enhance weight loss, but weight loss will positively address risk factors. Weight loss should not be initiated in pregnant or lactating patients, decompensated psychiatric patients, or patients in whom reduced caloric intake can exacerbate an acute, serious illness.6 Treatment of obesity includes lifestyle changes (dietary modification, enhanced physical activity, and behavioral therapy), pharmacologic treatment, surgical intervention, or a combination of modalities.

Four stages have been suggested for the treatment of obesity in children and adolescents. Stage 1 or Prevention Plus is the first step for overweight or obese patients and includes adherence to healthy eating and activity habits. Patients should be encourage to eat greater than or equal to five servings of fruits and vegetables daily, limit consumption of sweetened drinks, decrease television or other screen time behaviors, and increase physical activity to greater than or equal to 1 h/day. Stage 2 or Structured Weight Management incorporates Prevention Plus habits while setting specific eating and activity goals. Responsibilities include meal planning, observed physical activity or play daily for 1 hour and, documentation of energy consumption and expenditure. Comprehensive Multidisciplinary Interventions (Stage 3) is directed at increasing the intensity of healthy behaviors. To accomplish goals, the child or adolescent should work closely with the primary care provider, registered dietician, exercise specialist, and behavioral counselor. Stage 4, Tertiary Care Intervention, may be needed for the severely obese adolescents. A very low-calorie diet (LCD), medication or weight control surgery may be warranted. Treatment of obesity includes lifestyle changes (dietary modification, enhanced physical activity, and behavioral therapy), pharma-cologic treatment, surgical intervention, or a combination of modalities.

Table 102-4 Drugs Contributing to Weight Gain

Anticonvulsants/mood stabilizers Carbamazepine Gabapentin Valproic acid Lithium Antidepressants

Monoamine oxidase inhibitors (phenelzine) Presynaptic a-2 antagonist (mirtazapine) Selective serotonin reuptake inhibitors Tricyclics (amitriptyline, imipramine, nortryptyline)

Antidiabetics Insulin


Sulfonylureas (glyburide, glipizide) Thiazolidinediones Antipsychotics

Atypical (clozapine, olanzipine, risperidone, paliperidone, quetiapine) Others

Antihistamines Corticosteroids

Hormonal Contraceptives (depo injections)

From Refs. 26-28.

Table 102-5 Low-Calorie Step I Diet


Recommended Intake


Approximately 500-1,000 kcal/day

reduction from usual intake

Total fat*

30% or less of total calories

Saturated fatty acids'

8-10% of total calories


Up to 15% of total calories

fatty acids

Polyunsaturated fatty

Up to 10% of total calories



Less than 300 mg/day


Approximately 15% of total calories


55% or more of total calories

Sodium chloride

No more than 100 mmol/day

(approximately 2 A g of sodium or

approximately 6 g of sodium chloride)

<_alcium mg/day


20-30 g/day

"A reduction in calories of 500-1,000 kcal/day will help achieve a weight loss of 1 2 pounds/wk. Alcohol provides unneeded calories and displaces more nutritious foods. Alcohol consumption not only increases the number of calories in a diet but also has been associated with obesity in epidemiologic studies as well as in experimental studies. The impact of alcohol calories on a person's overall caloric intake needs to be assessed and appropriately controlled.

"Fat-modified foods may provide a helpful strategy for lowering total fat intake but will only be effective if they are also low in calories and if there is no compensation by calories from other foods.

'Patients with high blood cholesterol levels may need to use the Step II diet to achieve further reductions in LDL-cholesterol levels; in the Step II diet, saturated fats are reduced to less than 7% of total calories, and cholesterol levels to less than 200 mg/day. All of the other nutrients are the same as in Step I.

■'Proteins should be derived from plant sources and lean sources of animal protein.

'Complex carbohydrates from different vegetables, fruits, and whole grains are good sources of vitamins, minerals, and fiber. A diet rich in soluble fiber, including oat bran, legumes, barley, and most fruits and vegetables, may be effective in reducing blood cholesterol levels. A diet high in all types of fiber may also aid in weight management by promoting satiety at lower levels of calorie and fat intake. Some authorities recommend 20-30 g of fiber daily, with an upper limit of 35 g.

During weight loss, attention should be given to maintaining an adequate intake of vitamins and minerals. Maintenance of the recommended calcium intake of 1,000-1,500 mg/day is especially important for women who may be at risk of osteoporosis.

From U.S. Department of Health and Human Services, NIH-NHLBI. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Nil I publication no. 00-4084. Bethesda, MD: National Institutes of Health, 2000.

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