comfort, and convenience often seem to outweigh the benefits of a more active lifestyle. Nevertheless, increased physical activity makes successful weight loss more likely.
Many formerly obese people testify that establishing regular routines for physical activity was a turning point in maintaining lifestyle changes. Functional impairment and chronic pain are more prevalent among obese people compared with people in other weight groups (WHO 2000, Larsson 2002, Marcus 2004). Support from health care personnel may be necessary for clients to find ways to be physically active without increasing pain. Facilitating access to safe exercise offers special-needs clients a proven tool for weight-loss maintenance and improved health.
Drug Treatment
For some people, drug therapy for weight loss can be a short-term adjunct to behavior change, meal planning, and activity. Drug treatment may be considered for patients with a BMI ≥30 kg/m2 if treatment with diet, exercise, and behavior change has proven insufficient to reach goals. Drug treatment can also be considered for patients with substantial comorbidities associated with a BMI ≥27 kg/m2 (NIDDK 2007) that have persisted despite improved diet, exercise, and behavior treatment. Although drugs cannot override poor eating habits for sustained weight loss, they can make successful weight loss more attainable and support continued behavior change. Drug therapy can support weight maintenance as well as weight loss.
There have been two types of weight-management drugs. One type targets the gastrointestinal system to inhibit nutrient absorption or cause a feeling of satiety. The other acts on the central nervous system to influence feeding behavior and suppress appetite. For many years there was one available drug for each of these types. The first, orlistat, is now available over-the-counter in a reduced dose and by prescription (FDA 2010a). Late in 2010, the second drug, sibutramine, which acts on the central nervous system, was removed from the market due to increased cardiac risks (FDA 2010b). A few months later, the FDA removed a supplement (Fruta Planta) from the market when it was found to contain that same drug (FDA 2011a). Before the end of 2010, the FDA also denied approval for two new obesity drugs (Qnexa and Lorcaserin) (Pollack 2010a,b) and granted preliminary approval to a third. Providers were hopeful, as the third drug (Contrave) was a combination of two drugs already on the market, but early in 2011, the third drug was sent back for additional testing (FDA 2011b).
Given the overwhelming rise in obesity, there is an ever-growing demand for treatment options. Because millions will take a new weight-loss drug and the risks for adverse reactions are high, the FDA seeks evidence that a drug’s benefits clearly outweigh the risks before allowing it to reach the market.
To ensure safety and efficacy, WHO, NIH, and others emphasize that these drugs are only for weight management conducted with medical supervision and in combination with behavior change therapy. Weight-loss drugs do not offer successful treatment for those unwilling to make changes.
Keep in mind that medications for other problems may also influence weight-reduction efforts. If extra eating stems from feelings of depression, appropriate treatment for depression may aid weight loss. On the one hand, many antidepressants stimulate hunger and could have the opposite effect.
For people living with diabetes, understanding how diabetes medications impact hunger is the key to managing weight. To regulate blood glucose levels, digested food and insulin must be available in the bloodstream at the same time. Biguanides plus the newer oral medications (DPP-4 inhibitors, incretin mimetics, and antihyperglycemic synthetic analogs) help accomplish this without the risk of providing or stimulating excess insulin.
Excessive or improperly timed insulin or insulin-stimulating oral diabetes medications may stimulate hunger and/or the need for extra snacking to avoid hypoglycemia. Two oral medications stimulate increased insulin production. Sulfonylureas are longer acting and taken once or twice a day. Meglitinides are shorter acting but must be taken 5–30 minutes before each meal. People treated with the longer-acting sulfonylurea are more likely to experience hypoglycemia in the late afternoon if they skip or eat too little for lunch. The trade off is more frequent dosing versus more attention to one’s eating schedule.
When treatment with insulin is necessary, understanding the action time of the insulin is essential for coordinating injections with food intake. For example, rapid-acting insulin peaks in 1–2 hours and best matches a balanced meal when taken within 15 minutes of the first bite of food. Among insulin pump users, a common problem is taking extra insulin to lower a high blood glucose level before the insulin already present in the bloodstream has finished working. This often results in hypoglycemia. This experience is usually unpleasant enough that those experiencing it want to feel better right away. There is a strong temptation to treat the hypoglycemia with more food than is needed, setting up a cycle of eating extra food, resulting in hyperglycemia that has to be treated with extra insulin, which leads to more hypoglycemia.
Preventing hypoglycemia does much to limit calorie intake. Treating hypoglycemia appropriately with 15–30 grams of carbohydrate also helps limit calorie intake. Treating hypoglycemia with a fat-containing food (such as peanut butter crackers or a candy bar) adds extra calories, slows the rate of carbohydrate absorption, delays recovery, and often leads to another high glucose reading. For further information about weight issues for those with diabetes, see Diabetes Nutrition Q & A for Health Professionals (ADA 2003).
The hunger that accompanies hyperglycemia itself may subside when diabetes is treated. A well-managed plan for blood glucose control makes a major contribution to weight management.
Apart from drug therapy for obesity, monitoring the side effects of other medications can help everyone avoid unnecessary barriers to weight-loss efforts.
Bariatric Surgery
Bariatric surgery provides another treatment option when dietary, exercise, and behavior change efforts supported by weight-reducing drugs (when available) prove insufficient to reduce health risks.
As the negative consequences of obesity increase and surgical techniques improve, the cost-to-risk ratio has improved, and bariatric surgery has become more common for people whose obesity is a serious health threat. In fact, the number of surgeries increased 10-fold during the six years between 1998 and 2004 (Kulick 2010).
Different surgical methods assist weight loss by reducing stomach size (restricting storage space), by reducing nutrient absorption, and/or by influencing hormones that reduce appetite. By reducing stomach capacity, excess food has nowhere to go, making the consequences of overeating rather unpleasant and reinforcing the habit of eating smaller portions. Surgeries that also reduce absorption result in greater weight loss but also in higher risks for malnutrition.
Guidelines suggest that appropriate patients are those with a BMI ≥40 kg/m2 or a BMI ≥35 kg/m2 with high-risk, life-threatening comorbid conditions (NIDDK 2009). Although surgical procedures are more expensive and come with higher risks for serious complications, preliminary research supports substantial improvement in comorbidities (Ayman 2010) that reduce overall risk (Picot 2009).
Early in 2011, the FDA lowered the cutoff point for the surgery that uses an adjustable gastric banding system. This device, implanted around the upper part of the stomach, limits the amount of food that can be eaten at one time and is now a treatment option for people with a life-threatening comorbid condition (including diabetes) and a BMI ≥30 kg/m2 instead of ≥35 kg/m2. People seeking this surgery must also be willing to make major changes to their lifestyle and eating habits. For those without an obesity-related comorbid condition, the BMI cutoff point for this surgery remains ≥40 (FDA 2011c).
Successful candidates for bariatric surgery have acceptable operative risks and are motivated, willing to become well informed, and willing to participate in continuing programs that support behavior change. The keys to successful bariatric surgery include changing behavior patterns, accessing support systems, and long-term follow-up (Dowd 2005). More specific recommendations address meal timing, portion control, food quality, and the need for exercise. Note that behavior change, exercise, follow-up, and support are the same ingredients required for success using nonsurgical approaches to weight-loss (Franz 2007).
Always Behavior Change
Regardless of the approach to weight loss, behavior change is a required