Behavior therapy and pharmacotherapy for obesity

The past, present, and future of behavioral obesity treatment

Over the last century, hundreds of evaluations have been conducted to examine weight-management interventions related to diet, physical activity, and behavior therapy. These investigations have contributed to a growing body of knowledge that has consistently advanced the field of obesity treatment, while also revealing some persistent challenges. This narrative review summarizes key findings from randomized controlled trials conducted in adults that have combined diet, physical activity, and behavior therapy, an approach variously referred to as behavioral treatment, comprehensive lifestyle modification, or intensive lifestyle intervention. The review shows that current behavioral approaches induce average reductions in baseline body weight of 5 to 10% at 6 to 12 months. Such losses have proven effective in reducing the risk of type 2 diabetes in persons with impaired glucose tolerance and in improving other obesity-related complications. These benefits have also been associated with reductions in healthcare costs. Despite these advances, behavioral treatment is challenged by the need for larger losses to achieve optimal improvements in health, by difficulties associated with maintaining weight loss, and by barriers limiting access to treatment. New anti-obesity medications, when combined with behavioral obesity treatment, hold promise of addressing the first two issues.

Liraglutide 3.0 mg and Intensive Behavioral Therapy (IBT) for Obesity in Primary Care: The SCALE IBT Randomized Controlled Trial

OBJECTIVE

Previous studies have shown additive weight loss when intensive behavioral therapy (IBT) was combined with weight-loss medication. The present multisite study provides the first evaluation, in primary care, of the effect of the Centers for Medicare and Medicaid Services-based IBT benefit, delivered alone (with placebo) or in combination with liraglutide 3.0 mg.

METHODS

The Satiety and Clinical Adiposity-Liraglutide Evidence in individuals with and without diabetes (SCALE) IBT was a 56-week, randomized, double-blind, placebo-controlled, multicenter trial in individuals with obesity who received liraglutide 3.0 mg (n = 142) or placebo (n = 140) as an adjunct to IBT.

RESULTS

At week 56, mean weight loss with liraglutide 3.0 mg plus IBT was 7.5% and 4.0% with placebo combined with IBT (estimated treatment difference [95% CI]-3.4% [-5.3% to -1.6%], P = 0.0003). Significantly more individuals on liraglutide 3.0 mg than placebo achieved ≥ 5% weight loss (61.5% vs. 38.8%; odds ratio [OR] 2.5% [1.5% to 4.1%], P = 0.0003), > 10% weight loss (30.5% vs. 19.8%; OR 1.8% [1.0% to 3.1%], P = 0.0469), and > 15% weight loss (18.1% vs. 8.9%; OR 2.3% [1.1% to 4.7%], P = 0.0311). Liraglutide 3.0 mg in combination with IBT was well tolerated, with no new safety signals identified.

CONCLUSIONS

In a primary care setting, Centers for Medicare and Medicaid Services-based IBT produced clinically meaningful weight loss at 56 weeks, enhanced by the addition of liraglutide 3.0 mg.

Effects of liraglutide on appetite, food preoccupation, and food liking: results of a randomized controlled trial

Background:

Some weight loss medications, including liraglutide 3.0 mg, are thought to facilitate weight loss by improving appetite control. However, no studies have evaluated their long-term appetitive effects.

Subjects/Methods:

This study examined changes in appetite in a subsample of 113 adults with obesity (76.1% female, 55.8% white, BMI = 38.8±4.8 kg/m²) who participated in a 52-week trial. Participants were randomized to intensive behavioral therapy alone (IBT-alone), IBT with liraglutide 3.0 mg/day (IBT-liraglutide), or IBT-liraglutide combined with a 12-week meal replacement diet (Multi-component). Participants rated their hunger, fullness after meals, liking of meals, and food preoccupation (all as experienced over the past week) using visual analogue scales (0-100 mm). Ratings were completed at baseline and 8 subsequent visits over the year.

Results:

At week 52, participants treated by IBT-alone lost 6.2±1.6% of baseline weight, compared with 11.8±1.6% and 12.1±1.5% in the IBT-liraglutide and Multi-component groups, respectively. Compared to IBT-alone, IBT-liraglutide participants reported larger reductions at week 6 in hunger (−0.3±4.2 vs −16.8±4.0 mm, p=.005) and food preoccupation (+0.2±3.7 vs −16.3±3.6 mm, p=.002) and larger increases in fullness (−5.1±3.2 vs +9.8±3.0 mm, p=.001). These significant differences persisted at all assessments through week 24. There were no differences between IBT-alone and IBT-liraglutide in meal liking. IBT-alone and Multi-component participants differed in hunger at week 6, and in food preoccupation at all assessments through week 24. Multi-component participants reported reduced liking of meals relative to the IBT-alone and IBT-liraglutide groups through weeks 40 and 52, respectively. There were no other differences among any groups at week 52.

Conclusions:

Consistent with short-term studies, IBT-liraglutide participants reported greater improvements in hunger, fullness, and food preoccupation than those assigned to IBT-alone. Differences in appetite persisted for 24 weeks but were not maintained at week 52, despite the relatively greater weight losses in the liraglutide-treated participants at the trial’s end.

Intensive Behavioral Therapy for Obesity Combined with Liraglutide 3.0 mg: A Randomized Controlled Trial

OBJECTIVE

The Centers for Medicare and Medicaid Services (CMS) covers intensive behavioral therapy (IBT) for obesity. The efficacy, however, of the specific approach has never been evaluated in a randomized trial, as described here. The 1-year trial also assessed whether the addition to IBT of liraglutide 3.0 mg would significantly increase weight loss and whether the provision of meal replacements would add further benefit.

METHODS

A total of 150 adults with obesity were randomly assigned to: IBT (IBT-alone), providing 21 counseling visits; IBT combined with liraglutide (IBT-liraglutide); or IBT-liraglutide combined for 12 weeks with a 1,000- to 1,200-kcal/d meal-replacement diet (Multicomponent). All participants received weekly IBT visits in month 1, every-other-week visits in months 2 to 6, and monthly sessions thereafter.

RESULTS

Ninety-one percent of participants completed 1 year, at which time mean (± SEM) losses for IBT-alone, IBT-liraglutide, and Muticomponent participants were 6.1 ± 1.3%, 11.5 ± 1.3%, and 11.8 ± 1.3% of baseline weight, respectively. Fully 44.0%, 70.0%, and 74.0% of these participants lost ≥ 5% of weight, respectively. The liraglutide-treated groups were superior to IBT-alone on both outcomes. Weight loss in all three groups was associated with clinically meaningful improvements in cardiometabolic risk factors.

CONCLUSIONS

The findings demonstrate the efficacy of IBT for obesity and the potential benefit of adding pharmacotherapy to this approach.

The Purdue Stepped Approach Model: Sequencing Community and Clinical Interventions to Reduce Cardiovascular Risk Factors

The Purdue Stepped Approach Model (PM) is applied to the reduction of cardiovascular risk factors. The PM is schema for service delivery that increases the intensity of interventions presented in a series. Community interventions are sequentially introduced followed by clinical programs. Benefits of community interventions and clinical programs are discussed which include target of a large number of people, optimal utilization of technology and human capital, responsiveness to individual differences, and increased likelihood of permanence of behavior change. Empirical support from community and clinical research are provided. The five steps of the model are described and an heuristic example is illustrated. The PM may expand the role of community health educators and may lead to the evolution of more inclusive means of delivering community and clinical health programs.

The Heterogeneity of Obesity: Fitting Treatments To Individuals - Republished Article

Body weight is regulated by a complex interaction of biological, behavioral, and cultural factors. The population as a whole is at risk for obesity because of increased intake of dietary fat, the consumption of calories in fewer meals per day, striking accessibility to palatable foods, and decreased physical activity. This risk may become a reality in individuals with certain biological predispositions (genetic tendency, low metabolic rate, increased fat cell number), specific eating patterns, and susceptibility to the extreme cultural pressure to be lean. These factors must be considered in establishing goals for treatment, which fall into medical and psychosocial categories. This includes defining a "reasonable" as opposed to "ideal" weight. A three-stage process is proposed for identifying the best treatment for an individual. This involves a classification decision, a stepped care decision, and then a matching decision. Criteria are provided for a comprehensive assessment of the overweight individual, and treatment options are reviewed for programs of varying intensity, cost, and risk.

The Purdue Stepped Approach Model

This article presents an implementation strategy for health counseling based on the Purdue Stepped Approach Model (PM). The PM increases the intensity of interventions presented in a series. Selected issues in behavioral and health counseling that led to the development of the model, including cost-effectiveness, response of clients to treatment, and client commitment to and involvement in the therapeutic process, are discussed. A description of and empirical support for the PM are provided. Procedures and an example of the model's application to health counseling are included. Several potential benefits of the stepped approach are also discussed.

Addressing obesity with pediatric patients and their families in a primary care office

Pediatric obesity is a prevalent condition that has devastating health consequences for children. If left untreated, it can result in adult obesity and related chronic health conditions. Special considerations need to be made for treatment in the pediatric population including an adjustment of treatment goals (weight maintenance vs weight loss) and treatment methodologies. Special emphasis needs to be made to support a child's development of healthy behavior choices. The use of medications should be avoided when possible because long-term health effects of pharmacotherapy treatment in children are unknown.

Predictors of Successful Weight Loss

The identification of variables in the early stages of treatment that are related to successful weight loss provides practitioners with important information. These factors may be assessed to determine the likelihood of future success. Weight loss at the beginning of treatment, depressive symptomatology, and social support, each of these has been shown to be predictive of long-term outcomes for weight loss efforts.

Predictors of attrition and weight loss success: Results from a randomized controlled trial

Attrition is a common problem in weight loss trials. The present analysis examined several baseline and early-treatment process variables, as predictors of attrition and outcome in a clinical trial that combined pharmacotherapy and behavior therapy for weight loss. Participants were 224 obese adults who were treated with sibutramine alone, lifestyle modification alone, combined therapy, or sibutramine plus brief lifestyle modification. Predictors included baseline characteristics (e.g., demographic, weight-related, psychological, and consumption-related variables), plus attendance, adherence, and weight loss in the early weeks of treatment. Outcomes were attrition and weight loss success (i.e., >or=5% reduction in body weight) at 1 year. Multivariable models, adjusting for other relevant variables, found that younger age and greater baseline depressive symptoms were related to increased odds of attrition (ps <or= 0.003). Greater early weight loss marginally reduced the odds of attrition (p = 0.06). Predictors of weight loss success at 1 year were Caucasian ethnicity (p = 0.04), lower baseline depressive symptoms (p = 0.04), and weight loss during the first 3 weeks of treatment (p < 0.001). Thus, depressive symptoms at baseline were a significant predictor of both attrition and weight loss success. As a process variable, early weight loss appears to have more predictive value than early attendance at treatment sessions or early adherence.

Changes in symptoms of depression with weight loss: results of a randomized trial

Recent studies of rimonabant have re-awakened interest in the possible adverse psychiatric effects of weight loss, as well as of weight loss medications. This study examined changes in symptoms of depression in 194 obese participants (age = 43.7 +/- 10.2 years; BMI = 37.6 +/- 4.1 kg/m(2)) in a 1-year randomized trial of lifestyle modification and medication. Participants were assigned to (i) sibutramine alone; (ii) lifestyle modification alone; (iii) sibutramine plus lifestyle modification (i.e., combined therapy); or (iv) sibutramine plus brief therapy. Participants completed the Beck Depression Inventory-II (BDI-II) at baseline and weeks 6, 10, 18, 26, 40, and 52. At 1 year, participants in combined therapy lost the most weight and those in sibutramine alone the least (12.1 +/- 8.8% vs. 5.5 +/- 6.5%; P < 0.01). Mean BDI-II scores across all participants declined from 8.1 +/- 6.9 to 6.2 +/- 7.7 at 1 year (P < 0.001), with no significant differences among groups. Despite this favorable change, 13.9% of participants (across the four groups) reported potentially discernible increases (>or= 5 points on the BDI-II) in symptoms of depression at week 52. They lost significantly less weight than participants in the rest of the sample (5.4 +/- 7.8% vs. 9.0 +/- 7.8%, respectively; P < 0.03). The baseline prevalence of suicidal ideation was 3.6%. Seven new cases of suicidal ideation were observed during the year, with three in lifestyle modification alone. Further research is needed to identify characteristics of obese patients at risk of negative mood changes (and suicidal ideation) in response to behavioral and pharmacologic therapies.

Weight loss as a treatment for obstructive sleep apnoea

Obesity is a major health problem in well-developed societies. It is frequently associated with metabolic, cardiovascular and psychological comorbid conditions. Besides, it is known that obesity constitutes a risk factor for obstructive sleep apnoea (OSA). Weight loss has been evaluated as a treatment for OSA. We reviewed the nature of the link between obesity and OSA as well as the conservative and surgical therapeutic approaches of obesity. We consider the effectiveness of weight loss alone or combined with other modalities of treatment in OSA. We conclude that although weight loss is important and can facilitate the treatment of OSA, it can rarely cure it without being associated to classical techniques, such as nasal continuous positive airway pressure (nCPAP).

Weight loss treatment and psychological well-being: a review and meta-analysis

Research suggests that weight loss treatment generally benefits psychological well-being but these effects have never been quantitatively reviewed. A meta-analysis of 117 weight loss treatment tests showed that weight loss treatment was associated with lowered depression and increased self-esteem. Treatment type moderated treatment effects on depression and self-esteem. Actual weight loss moderated treatment effects on self-esteem but not depression; only treatments that produced actual weight loss predicted increased self-esteem whereas improvements in depression were independent of weight loss. The clinical implications of the findings and the possible causal relationships among weight, depression and self-esteem are discussed.

Psychopathology and obesity

Obesity has historically been linked to emotional factors by clinicians and the lay public alike. Early psychiatric studies reinforced the popular perception that psychopathology is common among the overweight and plays an important role in the development of obesity. This notion has been challenged by recent investigations which suggest that psychological disturbances are more likely to be the consequences than the causes of obesity. Emotional difficulties faced by the obese may be largely attributable to an entrenched cultural contempt for the obese and a pervasive preoccupation with thinness.

Evaluation of a primary care-oriented brief counselling intervention for obesity with and without orlistat

OBJECTIVE

There is a significant need for an obesity treatment model suitable for the primary care environment. We examined the effectiveness of a brief counselling intervention alone, in combination with orlistat, and drug-alone in a 12-month randomized-clinical trial at a medical school obesity centre.

METHODS

Participants (N = 250) with body mass index (BMI) >or=27 were randomized. Changes in body weight, lipids, blood pressure and serum glucose were examined. Drug adherence and attendance were also evaluated.

RESULTS

Completers analysis was conducted on 136 participants with data at baseline, 6 and 12 months and intention-to-treat analyses (ITT) for the total sample. Amongst completers, participants in the drug only (P = 0.012) and drug + brief counselling (P = 0.001) groups lost more weight (mean +/- SD: -3.8 +/- 5.8 kg and -4.8 +/- 4.4 kg, respectively) than participants in the brief counselling only group at 6 months (-1.7 +/- 3.3 kg), but there were no significant group differences at 12 months. ITT model results were similar to completers at 6 months and remained significant at 12 months, but the weight losses were more modest (<3 kg) for both groups receiving orlistat. For brief counselling alone, participants gained weight (1.7 +/- 4.2 kg). Cardiovascular disease (CVD) parameter changes were negligible.

CONCLUSIONS

Pharmacotherapy alone or combined with brief counselling resulted in modest weight losses that had minimal impact on cardiovascular parameters, but were greater than brief counselling alone. Whilst brief interventions and primary pharmacotherapy have been suggested as viable treatments for implementation in primary care settings, our study suggests that such minimal interventions provide minimal benefits.

Child and parental self-monitoring as determinants of success in the treatment of morbid obesity in low-income minority children

OBJECTIVE

To examine self-monitoring by children and parents as related to weight control over 6 months within a long-term multidisciplinary program for low-income minority children with morbid obesity.

METHODS

The weight changes of 228 children with obesity were evaluated according to frequency of child and parental self-monitoring. Predictors of self-monitoring were also evaluated.

RESULTS

Children who self-monitored on most days lost more weight over 6 months of treatment compared with less-consistent self-monitors. Children whose parents self-monitored were also more likely to self-monitor and lose weight.

CONCLUSIONS

Self-monitoring seems just as critical for successful weight control among low-income minority children with obesity as it is in the middle-class populations. Although lower education and higher levels of psychosocial stress may decrease self-monitoring and participation by these families, they might still benefit from targeting highly consistent self-monitoring (by parents and children) as a primary goal in weight-control programs.

Effect of sibutramine and of cognitive-behavioural weight loss therapy in obesity and subclinical binge eating disorder

AIM

In this randomized, double-blind, placebo-controlled study, the effect of sibutramine and cognitive-behavioural weight loss (cognitive-BWL) treatment was assessed in obese subjects with and without subclinical binge eating disorder (sBED).

METHODS

Seventy-three obese participants were recruited from the community, 29 with and 44 without sBED. Subjects were randomly assigned to a 16-week treatment with either sibutramine or placebo while simultaneously participating in a cognitive-behavioural weight loss treatment.

RESULTS

Intent-to-treat analysis showed moderate weight loss after treatment in all subject groups. Treatment with BWL programs and sibutramine leads to a higher weight loss in all subjects compared with that in patients who had undergone BWL programs alone. Subjects with sBED significantly reduced their binge episodes during treatment, but with no augmenting effect of sibutramine.

DISCUSSION

Our results yield further evidence that sBED is associated with characteristics comparable with full-syndrome BED, significantly differing from those of obesity alone. These findings call for a systematic assessment of eating behaviour before starting obesity treatment.

Randomized trial of lifestyle modification and pharmacotherapy for obesity

BACKGROUND

Weight-loss medications are recommended as an adjunct to a comprehensive program of diet, exercise, and behavior therapy but are typically prescribed with minimal or no lifestyle modification. This practice is likely to limit therapeutic benefits.

METHODS

In this one-year trial, we randomly assigned 224 obese adults to receive 15 mg of sibutramine per day alone, delivered by a primary care provider in eight visits of 10 to 15 minutes each; lifestyle-modification counseling alone, delivered in 30 group sessions; sibutramine plus 30 group sessions of lifestyle-modification counseling (i.e., combined therapy); or sibutramine plus brief lifestyle-modification counseling delivered by a primary care provider in eight visits of 10 to 15 minutes each. All subjects were prescribed a diet of 1200 to 1500 kcal per day and the same exercise regimen.

RESULTS

At one year, subjects who received combined therapy lost a mean (+/-SD) of 12.1+/-9.8 kg, whereas those receiving sibutramine alone lost 5.0+/-7.4 kg, those treated by lifestyle modification alone lost 6.7+/-7.9 kg, and those receiving sibutramine plus brief therapy lost 7.5+/-8.0 kg (P<0.001). Those in the combined-therapy group who frequently recorded their food intake lost more weight than those who did so infrequently (18.1+/-9.8 kg vs. 7.7+/-7.5 kg, P=0.04).

CONCLUSIONS

The combination of medication and group lifestyle modification resulted in more weight loss than either medication or lifestyle modification alone. The results underscore the importance of prescribing weight-loss medications in combination with, rather than in lieu of, lifestyle modification.

Medications as Adjunct Therapy for Weight Loss: Approved and Off-Label Agents in Use

Although a nutritionally balanced, energy-controlled diet and regular exercise form the cornerstone of weight management, supporting therapies may include antiobesity medications when a clinician determines that pharmacologic assistance could contribute to treatment success. The US Food and Drug Administration has approved certain medications for helping achieve weight loss in patients with obesity or overweight who have comorbidities. However, some clinicians prescribe medications not approved for weight loss for this purpose. Evidence from clinical trials indicates that weight loss resulting from the use of many of these off-label pharmaceutical agents is modest, but in a range that correlates with favorable modification of cardiovascular risk factors, and significant when compared with placebo plus diet and lifestyle modification. Clinical trials also demonstrate a slight but significant effect in the weight-maintenance phases following weight loss. Pharmacotherapy alone, without behavior modification, is not effective; patients who respond to medication typically regain weight when the drug is discontinued. The fact that many weight-loss medications are sold over the Internet without a prescription suggests that they are being used without medical supervision. The purpose of this review is to present evidence for and against the obesity medications currently used in clinical practice, and the possible role for these agents in a person's overall weight loss plan.

Pharmacotherapy for weight loss in adults with type 2 diabetes mellitus

BACKGROUND

Obesity is closely related to type 2 diabetes and long-term weight reduction is an important part of the care delivered to obese persons with diabetes.

OBJECTIVES

To assess the efficacy of pharmacotherapy for weight loss in adults with type 2 diabetes.

SEARCH STRATEGY

Computerized searches were performed of MEDLINE (January 1966 to May 2004), EMBASE (January 1974 to May 2004, Web of Science (January 1981 to May 2004, and other electronic bibliographic databases, supplemented with hand searches of reference lists and selected journals.

SELECTION CRITERIA

Randomized, controlled trials were included where pharmacotherapy was used as the primary strategy for weight loss among adults with type 2 diabetes. Published and unpublished literature in any language and with any study design was included.

DATA COLLECTION AND ANALYSIS

Two reviewers abstracted data and the quality of included studies was evaluated by assessing potential attrition, as well as selection and measurement bias, and a Jadad score was obtained. Effects were combined using a random effects model.

MAIN RESULTS

A sufficient number of studies were available for a quantitative synthesis for fluoxetine, orlistat, and sibutramine. Twenty two randomized controlled trials were included in the review, with a total of 296 participants for fluoxitine, 2036 for orlistat, and 1047 for sibutramine. Pharmacotherapy produced modest reductions in weight for fluoxetine (5.1 kg (95% confidence interval [CI], 3.3 - 6.9) at 24 to 26 weeks follow up; orlistat 2.0 kg (CI, 1.3 - 2.8) at 12 to 57 weeks follow-up, and sibutramine 5.1 kg (CI, 3.2 - 7.0) at 12 to 52 weeks follow-up. Glycated hemoglobin also modestly and significantly reduced for fluoxetine and orlistat. Gastrointestinal side effects were common with orlistat; tremor, somnolence and sweating with fluoxetine; and palpitations with sibutramine. Some studies, using a variety of study designs, were available on other drugs and a significant decrease in weight was noted in three studies of mazindol, one of phenmetrazine, two of phentermine. No studies were identified that fit inclusion criteria for pseudophedrine, ephedra, sertraline, yohimbine, amphetamine or its derivatives, bupropion, topiramate, benzocaine, threachlorocitric acid, sertraline, and bromocriptine.

AUTHORS' CONCLUSIONS

Fluoxetine, orlistat, and sibutramine can achieve statistically significant weight loss over 12 to 57 weeks. The magnitude of weight loss is modest, however, and the long-term health benefits remain unclear. The safety of sibutramine is uncertain. There is a paucity of data on other drugs for weight loss or control in persons with type 2 diabetes.

Effects of booster interventions on factory workers' use of hearing protection

BACKGROUND

The provision of reinforcements or boosters to interventions is seen as a logical approach to enhancing or maintaining desired behavior. Empirical studies, however, have not confirmed the effectiveness of boosters nor assessed the optimum number of boosters or the timing for their delivery.

OBJECTIVES

This randomized controlled trial contrasted the effect of four booster conditions (a). 30 days; (b). 90 days; (c). 30 and at 90 days; and (d). no boosters of the intervention to increase the use of hearing protection devices (HPDs).

METHODS

A total of 1325 factory workers completed a computerized questionnaire and were randomly assigned to one of three computer-based (tailored, nontailored predictor-based, or control) multimedia interventions designed to increase the use of hearing protection devices. After the intervention, colorful boosters specific to the type of training received were mailed to workers' homes. Posttest measures of use were administered at the time of their next annual audiogram 6 to 18 months after the intervention. RESULTS Repeated measures of analysis of variance (ANOVA) showed a significant main effect for the booster (after 30 days) in the group that received tailored training (F[3442] = 2.722; p =.04). However, in the assessment of the interaction between time (pretest and posttest) and boosters (four groups), the ANOVA did not find significant differences in hearing protection device use for any of the training groups. To assess for significant differences between groups, post hoc comparisons were conducted at the pretest and posttest for the total sample and for the subsample of workers who reported using hearing protection devices less than 100% of the time needed. Sheffé contrasts by intervention group, gender, ethnicity, and hearing ability found no significant changes in the mean use of hearing protection devices for the booster groups.

CONCLUSIONS

Although the provision of boosters represented a considerable commitment of resources, their use was not effective in this study. However, it would be premature to eliminate boosters of interventions. Further study is needed to explore the effects of different booster types for increasing the use of hearing protection devices, and to assess carefully the effects of boosters on other health behaviors in studies with controlled designs.

Obesity: responding to the global epidemic

Obesity has reached epidemic proportions in the United States and other developed nations. In the United States, 27% of adults are obese and an additional 34% are overweight. Research in the past decade has shown that genetic influences clearly predispose some individuals to obesity. The marked increase in prevalence, however, appears to be attributable to a toxic environment that implicitly discourages physical activity while explicitly encouraging the consumption of supersized portions of high-fat, high-sugar foods. Management of the obesity epidemic will require a two-pronged approach. First, better treatments, including behavioral, pharmacologic, and surgical interventions, are needed for individuals who are already obese. The second and potentially more promising approach is to prevent the development of obesity by tackling the toxic environment. This will require bold public policy initiatives such as regulating food advertising directed at children. The authors call not for the adoption of a specific policy initiative, but instead propose that policy research, based on viewing obesity as a public health problem, become a central focus of research.

Combining behavioral and pharmacological treatments for obesity

Weight-loss medications are currently recommended for use only as an adjunct to diet, exercise, and behavior modification. Little, however, is known about the benefits of combining behavioral and pharmacological therapies or about the mechanisms that would make these combined approaches more effective than either used alone. This article reviews the effects of adding pharmacotherapy (i.e., principally sibutramine and orlistat) to a modest program of lifestyle modification. Studies revealed that the addition of medication typically improved short- and long-term weight loss compared with lifestyle modification alone. The best results, however, were obtained when medications were combined with an intensive, group program of lifestyle modification. The two approaches may have additive effects; behavioral treatment seems to help obese individuals control the external (i.e., food-related) environment, whereas pharmacotherapy may control the internal environment by reducing hunger, cravings, or nutrient absorption. The article examines possible methods of sequencing behavioral and pharmacological therapies and offers suggestions for future research.

American College of Sports Medicine position stand. Appropriate intervention strategies for weight loss and prevention of weight regain for adults

In excess of 55% of adults in the United States are classified as either overweight (body mass index = 25-29.9 kg.m(-2)) or obese (body mass index > or = 30 kg.m(-2)). To address this significant public health problem, the American College of Sports Medicine recommends that the combination of reductions in energy intake and increases in energy expenditure, through structured exercise and other forms of physical activity, be a component of weight loss intervention programs. An energy deficit of 500-1000 kcal.d-1 achieved through reductions in total energy intake is recommended. Moreover, it appears that reducing dietary fat intake to <30% of total energy intake may facilitate weight loss by reducing total energy intake. Although there may be advantages to modifying protein and carbohydrate intake, the optimal doses of these macronutritents for weight loss have not been determined. Significant health benefits can be recognized with participation in a minimum of 150 min (2.5 h) of moderate intensity exercise per week, and overweight and obese adults should progressively increase to this initial exercise goal. However, there may be advantages to progressively increasing exercise to 200-300 min (3.3-5 h) of exercise per week, as recent scientific evidence indicates that this level of exercise facilitates the long-term maintenance of weight loss. The addition of resistance exercise to a weight loss intervention will increase strength and function but may not attenuate the loss of fat-free mass typically observed with reductions in total energy intake and loss of body weight. When medically indicated, pharmacotherapy may be used for weight loss, but pharmacotherapy appears to be most effective when used in combination with modifications of both eating and exercise behaviors. The American College of Sports Medicine recommends that the strategies outlined in this position paper be incorporated into interventions targeting weight loss and the prevention of weight regain for adults.

Influence of antidepressant pharmacotherapy on behavioral treatment adherence and smoking cessation outcome in a combined treatment involving fluoxetine

The authors examined whether serum fluoxetine levels influence behavioral treatment adherence and smoking cessation outcome. Nondepressed smokers (N = 989) from 16 centers were randomized on a double-blind basis to receive either fluoxetine (30 or 60 mg) or placebo plus 9 sessions of behavioral smoking cessation treatment. Fluoxetine and norfluoxetine blood levels were assayed 1 week after the quit date. Logistic regression was used to predict treatment completion and cessation outcome, controlling for gender, age, treatment site, and degree of nicotine dependence. Higher steady-state fluoxetine blood levels (fluoxetine + norfluoxetine) predicted less likelihood of dropping out, chi2(1, N = 820) = 3.9, p < .05, and more likelihood of being abstinent, chi2(1, N = 513) = 18.1, p < .001. Attaining a higher fluoxetine blood level improved the likelihood of completing behavioral treatment and increased the probability of achieving abstinence.

Medical management of obesity

Obesity has become a major health problem in many countries because of its high prevalence and causal relationship with serious medical complications. Many of the medical complications associated with obesity improve with intentional weight in a dose-dependent fashion, and even a modest weight loss of 50% of initial weight has beneficial effects. This article reviews the nonsurgical approaches for achieving weight loss in obese persons.

Current status of medical and surgical therapy for obesity

The incidence of obesity (especially childhood obesity) and its associated health-related problems have reached epidemic proportions in the United States. Recent investigations suggest that the causes of obesity involve a complex interplay of genetic, environmental, psychobehavioral, endocrine, metabolic, cultural, and socioeconomic factors. Several genes and their protein products, such as leptin, may be particularly important in appetite and metabolic control, although the genetics of human obesity appear to involve multiple genes and metabolic pathways that require further elucidation. Severe obesity is frequently associated with significant comorbid medical conditions, including coronary artery disease, hypertension, type II diabetes mellitus, gallstones, nonalcoholic steatohepatitis, pulmonary hypertension, and sleep apnea. Long-term reduction of significant excess weight in these patients may improve or resolve many of these obesity-related health problems, although convincing evidence of long-term benefit is lacking. Available treatments of obesity range from diet, exercise, behavioral modification, and pharmacotherapy to surgery, with varying risks and efficacy. Nonsurgical modalities, although less invasive, achieve only relatively short-term and limited weight loss in most patients. Currently, surgical therapy is the most effective modality in terms of extent and duration of weight reduction in selected patients with acceptable operative risks. The most widely performed surgical procedure, Roux-en-Y gastric bypass, achieves permanent (followed up for more than 14 years) and significant weight loss (more than 50% of excess body weight) in more than 90% of patients.

Behavioral treatment of obesity

The behavioral treatment of obesity consists of a set of principles and techniques to help overweight individuals modify inappropriate eating and activity habits. As provided in University and hospital clinics, this approach produces an average loss of 8.5 kg (9% of initial weight) in approximately 20 weeks. The maintenance of weight loss is facilitated by the provision of long-term patient-provider contact as well as by the use of weight-loss medications. The most promising results are likely to be obtained when behavioral and pharmacologic approaches are combined. The article concludes with a discussion of the importance of treating obese individuals with respect and compassion.

The treatment of obesity: what's new, what's recommended

The prevalence of obesity in the United States has increased, with approximately one third of American men and women considered obese. Obese individuals who seek weight reduction frequently lose weight with the goal of returning to their ideal body weight. For the majority of obese persons, however, reaching their ideal body weight is an unattainable goal, few people are able to maintain even more modest weight losses over the long term. The result is that many obese persons end up feeling frustrated, if not defeated, by their weight loss efforts. Recent weight loss treatment recommendations have focused on helping patients lose 5%-10% of their body weight and maintaining these losses for longer durations. These more modest losses frequently are associated with reductions in obesity-related comorbidities and improvements in psychological status. The practitioner assisting obese individuals with weight reduction is presented with a variety of treatment options, including behavioral programs, pharmacotherapy, and low-calorie diets. Each of these approaches has been shown to be effective in producing the 5%-10% weight losses now recommended. A combination of these approaches, such as the use of pharmacotherapy with a behavioral modification program, ultimately may prove to be the most effective treatment for obese persons. We review the new weight loss recommendations and provide suggestions for assessing patients for weight loss treatment. We also discuss both existing and new treatment options and focus on their application in a primary care setting.

Sibutramine produces dose-related weight loss

OBJECTIVE

Sibutramine is a weight control drug that inhibits the reuptake of both serotonin and norepinephrine. In animals, it reduces food intake and increases thermogenesis and preliminary data in human beings showed weight loss. This paper reports a 24-week dose-ranging study to determine the effect of sibutramine on body weight of patients with obesity.

RESEARCH METHODS AND PROCEDURES

Seven clinical centers screened 1463 patients with obesity and randomized 1047 to 24 weeks of treatment with 1 of 6 doses of sibutramine (1, 5, 10, 15, 20, or 30 mg) or placebo once daily. Six hundred eighty-three patients completed the study. A two-week placebo run-in period was used to initiate a standardized program of diet, physical activity, and lifestyle changes.

RESULTS

Weight loss was dose-related and statistically significant vs. placebo (p<0.05) across all time-points for a 5 mg/day to 30 mg/day dosage of sibutramine. At week 24, percent weight loss from baseline for completers was: placebo, 1.2%; 1 mg, 2.7%; 5 mg, 3.9%; 10 mg, 6.1%; 15 mg, 7.4%; 20 mg, 8.8%; and 30 mg, 9.4%. Weight loss achieved at week 4 was predictive of weight loss achieved at week 24. Patients losing weight demonstrated an increase in serum high density lipoprotein cholesterol and reductions in serum triglycerides, total cholesterol, low density lipoprotein cholesterol, and uric acid. Small mean increases in blood pressure and pulse rate (with considerable individual variability) were observed in patients treated with sibutramine. The most frequent adverse events were dry mouth, anorexia, and insomnia.

DISCUSSION

Sibutramine administered once daily for 24 weeks in the weight loss phase of treatment for uncomplicated obesity produced dose-related weight loss and was well tolerated. Improvements in serum lipids and uric acid accompany sibutramine-induced weight loss. Most of the adverse events observed on sibutramine are related to its pharmacology, including small mean increases in blood pressure and heart rate.

A model for chronic care of obesity through dietary treatment

Obesity is rapidly increasing to epidemic proportions. At the same time, obesity is not well accepted as a disease among health professionals or insurance companies. The primary care physician is often forced to ignore the obesity and treat the associated risks, and the dietitian is often compelled to treat the disease for only short periods and for little reimbursement. Therefore, to treat obesity more effectively both clinically and economically, it is necessary to create a health care team. This can be done by joining the dietitian and the primary care physician, even if each health professional sees patients at a different site. Through mutual referrals and more consistent coordination of care, the team can provide cost-effective management of obesity while providing improved clinical monitoring of the patient. Both members of the team need to understand the pathophysiology of obesity and when to refer to each other. The dietitian will see the patient more regularly throughout all stages of the obesity treatment, referring to the physician when appropriate (eg, for evaluation of medications, new laboratory tests, and electrocardiography). The physician will see the patient in the acute stage (i.e., weight change stage) of the obesity treatment for any clinical changes, but will schedule less frequent visits during the chronic stage (i.e., weight maintenance). The strength of the team, therefore, lies in its members' ability to communicate with each other, monitor the clinical changes concomitant with fluctuating weight, and offer treatment and support as intensively as the disease warrants.

Lifestyle modification in the pharmacologic treatment of obesity: a pilot investigation of a potential primary care approach

This study examined a new method of providing brief, individual lifestyle modification to obese individuals treated by pharmacotherapy. Twenty-six women with a mean (+/- SD) age of 47.0 +/- 7.2 years, weight of 97.6 +/- 13.0 kg, and body mass index of 36.5 +/- 5.0 kg/m2 were prescribed 60 mg/d of fenfluramine and 15 mg/d of phentermine for one year. In addition, half of the women were randomly assigned to traditional group behavior modification, conducted by a nutritionist, which included 32 75-minute sessions during the year. The other half were provided lifestyle modification by a physician during 10 15-20 minute structured visits. All participants received identical treatment manuals and comparable assignments for behavior change. At the end of one year, patients in the physician group achieved the same highly successful weight losses as those treated by group behavior modification (13.9 +/- 9.6 kg vs. 15.4 +/- 7.9 kg, respectively). Treatment was associated with highly significant improvements in lipids and lipoproteins, as well as in mood and several measures of appetite. Weight loss the first four weeks, as well as patient completion of daily food records during the first 18 weeks, correlated positively with weight loss at weeks 18, 26, and 52. Results of this study await replication using larger samples but strongly suggest that effective lifestyle modification can be provided during brief, structured physician visits. The findings are discussed in terms of their implications for the treatment of obesity in primary care practice.

Behavioral therapy for obesity

The research literature pertaining to behavior therapy for obesity is reviewed. Procedures used in behavioral treatment programs are described, and treatment outcome research is reviewed. During the past 30 years, average weight loss has increased, but the problem of regaining body weight following treatment has persisted. It was concluded that obesity should be treated as a chronic health problem and that behavior therapy may have an important role in assisting some obese persons to maintain weight loss if they are enrolled in very long-term treatment programs.

Current views on obesity

Although the disorders associated with obesity have been extensively studied, little attention has been paid to the fact that obesity is itself a chronic disease. This misunderstanding of the nature of obesity has contributed to the stigmatization of obese persons and to the use of inappropriate or inadequate treatment regimens. Although the etiology of obesity is still unclear, genetic, metabolic, and social factors are all believed to play a role in its development and progression. Behavioral therapy, exercise, very-low-calorie diets, drug therapy, and surgery affect the treatment of obesity of differing levels of severity. The regaining of weight following treatments other than surgery is very frequent, in part because periods of weight loss are rarely followed by maintenance programs. An increasing awareness of the chronic, multifactorial nature of obesity will ideally lead to the development of new long-term treatment programs that are safe and effective. Such programs are urgently needed in light of new data that show that the prevalence of obesity is increasing in the United States, as much as 30% in the last decade.

Depressive symptoms in overweight and obese older adults: a test of the "jolly fat" hypothesis

The association between body weight and depressive symptoms in older adults was examined in a population-based study of 2,245 noninstitutionalized men and women aged 50 to 89 years living in Rancho Bernardo, California, U.S.A. The prevalence of Beck Depression Inventory scores > or = 13 was inversely associated with body weight in men, but not in women. Overweight and obese 50- to 69-yr-old women were more depressed than women with a body mass index below 25 kg/m2, but the difference was only marginally significant (p = 0.09). When age, health status and medication use were controlled, the odds of being depressed were 0.34 (p = 0.004) in overweight men and 0.28 (p = 0.09) in obese men, compared to men with a body mass index below 25 kg/m2. In this cohort, depression in men was inversely associated with body weight, supporting the "Jolly Fat" hypothesis. The likelihood that more stigma is attached to excessive weight in women than men may account for the lack of an inverse association between weight and depression in women.

Management strategies for weight control. Eating, exercise and behaviour

Obesity is a major health and social problem worldwide for which no single satisfactory treatment exists. Because of the prevalence of the disease, numerous therapeutic strategies have been attempted--often unsuccessfully. Weight loss programmes based on dietary restriction of caloric intake and nutritional education, exercise, surgical (gastroplasty, gastric bypass) and procedural (gastric balloon, waist cord, jaw wiring, liposuction) intervention and pharmacotherapy (appetite suppressants, thermogenic agents, bulking agents) used alone or in combination, have produced weight loss in the short to medium term; however, weight is generally regained on discontinuation of treatment. Behaviour modification programmes appear to offer the highest success rate in the long term. Weight loss is not rapid, although losses of 10 to 15 kg have been achieved after 6 months, and this may be increased when behaviour modification therapy is combined with more aggressive treatments such as severe caloric restriction or jaw wiring. Behaviour modification is particularly beneficial in special patient groups such as the obese elderly, children or adolescents, and disabled patients. Thus, although it appears that each of the treatments developed for the management of obese patients has its place, the cornerstone of therapy for most patients remains a programme of dietary restriction, combined with exercise and behaviour modification.