Finally: Best practices available for obesity
Finally: Best practices available for obesity
Government releases first obesity guidelines
Over the last 30 years, the prevalence of obesity in the United States has continuously spiraled upward. Despite the '80s aerobics craze and the '90s smorgasbord of low-fat food offerings, obesity in adults increased from nearly 13% of the population in 1960 to 22.5% in 1994. Add in the people who are overweight but not obese, and you've got a problem that affects 97 million American adults, or 55% of the population.
Endocrinologists have argued for several years that obesity should be treated as a chronic disease but have found themselves battling the public perception that fat people ought to just quit eating so much and get off their couches. Now they finally have some backup: The Bethesda, MD-based National Heart, Lung, and Blood Institute recently released the first clinical practice guidelines for the identification, evaluation, and treatment of overweight and obesity in adults.
The report points out that numerous studies have shown that being overweight (having a body mass index over 25) or obese (having a BMI over 30) substantially increases the risk of hypertension, lipid disorders, Type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and certain cancers. The total cost of obesity-related disease approaches $100 billion annually.
"The evidence is solid that the risk for various cardiovascular and other diseases rises significantly when someone's BMI is over 25 and that risk of death increases as the BMI reaches and surpasses 30," says Xavier Pi-Sunyer, MD, chairman of the expert panel and director of the Obesity Research Center at St. Luke's Roosevelt Hospital in New York City. "The guidelines tell the truth about the risks associated with unhealthy weight. We hope that physicians and the public will take the message seriously and use the guidelines to begin to deal effectively with a difficult problem."
Before these guidelines were released, there was no one-stop shop for information on obesity and not a lot of consensus on what constituted safe, effective treatment. Consider last year's fen/phen fiasco, when many obese patients who thought they had found a magic bullet cure discovered that they may actually have bought themselves a ticket to heart disease. That situation resulted in the withdrawal of fenfluramine (Pondimin) or dexflenfluramine (Redux) from the market and the realization that more study was needed on the long-term use of weight-loss drugs.
The NHLBI guidelines, developed by a 24-member panel and reviewed by 115 experts, address fen/phen and other drugs as well as a whole host of other issues that should be considered in assessing obesity and managing weight. They are based on an extensive review and systematic analysis of the published scientific literature between 1980 and 1997, including evidence from 394 randomized controlled trials.
Recommendations include:
o Practitioners should use BMI to assess overweight and obesity. All people with a BMI over 25 should have their risk factors assessed, including cigarette smoking, hypertension, high LDL cholesterol, low HDL cholesterol, family history of premature heart disease and lack of physical activity.
o The waist circumference should be used to assess abdominal fat content. A circumference of more than 35 inches in women and more than 40 inches in men signifies increased risk of disease.
o The initial goal of weight loss therapy should be to reduce body weight by approximately 10% from baseline.
o Weight loss should be about 1 to 2 pounds per week for a period of six months. A diet that is individually planned to help create a deficit of 500 to 1,000 kcal/day should be an integral part of the program.
Reducing dietary fat alone, without reducing calories, will not produce weight loss. Cutting back on dietary fat can help reduce calories and is heart-healthy.
o Patients should engage in moderate physical activity, progressing to 30 minutes or more on most - or preferably all - days of the week.
Physicians should have their patients try lifestyle therapy for at least six months before embarking on drug therapy. Weight-loss drugs approved by the FDA for long-term use may be tried as part of a comprehensive program that includes dietary therapy and physical activity in carefully selected patients (BMI over 30 without additional risk factors or BMI over 27 with two or more risk factors who have been unable to lose weight with nondrug therapies.).
Weight-loss drug safety and effectiveness beyond one year of total treatment have not been established.
Practitioners should assess the patient's motivation to enter weight loss therapy; assess the readiness of the patient to implement the plan and then take appropriate steps to motivate the patient for treatment.
"This is in essence a program to change lifestyle habits that focuses on simple ways to break old habits and develop new, healthier ones," Pi-Sunyer says. "It can be done by an interested primary care physician who will keep up contact with the patient to ensure the continuation of the lifestyle changes that helped in weight loss."
Karen Donato, coordinator of the NHLBI's Obesity Education Initiative and executive director of the panel, says the panel came across evidence that showed Americans are consuming 300 more calories per day than they did 20 years ago and that nearly 30% of adults participate in no leisure-time physical activity.
"It's easy for Americans today to fall into a pattern of overeating and being sedentary," Donato says. "They often eat out. Portion sizes are larger than ever. Low-fat products are everywhere and are deceptively tempting. Unfortunately, there is no free ride. Calories count, and it's very easy to tip the energy balance."
The guidelines point out that some low- or non-fat foods actually have the same or more calories than their regular counterparts. A half-cup of regular ice cream, for example, has fewer calories than the same amount of premium non-fat frozen yogurt.
"For many Americans, weight management is a daily struggle, and weight loss an endless quest," Donato says. "We hope these guidelines will help doctors and their patients work together in this effort."
The NHLBI is preparing a practical guide version of the full 228-page report that will be distributed to primary care physicians and other providers. The shorter version will include much of the consumer-oriented information in the full report, including menus, the low-calorie shopping list, tips on how to choose and prepare lower-fat foods, and advice on how to eat healthy when dining out. The full report appears in September's issue of the journal Obesity Research, and the executive summary is forthcoming in the Archives of Internal Medicine.
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