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10. How to achieve weight loss

The panel reviewed relevant treatment strategies designed for weight loss that can also be used to foster long-term weight control and prevention of weight gain. The consequent recommendations emphasize the potential effectiveness of weight control using multiple interventions and strategies, including dietary therapy, physical activity, behavior therapy, pharmacotherapy, and surgery, as well as combinations of these strategies.

 1. Dietary Therapy

The panel reviewed 86 RCT articles to determine the effectiveness of diets on weight loss (including LCDs, very low-calorie diets (VLCDs), vegetarian diets, American Heart Association dietary guidelines, the NCEP’s Step I diet with caloric restriction, and other low-fat regimens with varying combinations of macronutrients). Of the 86 articles reviewed, 48 were accepted for inclusion in these guidelines.

These RCTs indicate strong and consistent evidence that an average weight loss of 8 percent of initial body weight can be obtained over 3 to 12 months with an LCD and that this weight loss effects a decrease in abdominal fat; and, although lower-fat diets without targeted caloric reduction help promote weight loss by producing a reduced caloric intake, lower-fat diets with targeted caloric reduction promote greater weight loss than lower-fat diets alone.

Further, VLCDs produce greater initial weight losses than LCDs (over the long term of >1 year, weight loss is not different than that of the LCDs). In addition, randomized trials suggest that no improvement in cardio respiratory fitness as measured by VO2 max appears to occur in obese adults who lose weight on LCDs alone without physical activity. The following recommendations are based on the evidence extracted from the 48 accepted articles:

LCDs are recommended for weight loss in overweight and obese persons. Evidence Category A. Reducing fat as part of an LCD is a practical way to reduce calories. Evidence Category A. Reducing dietary fat alone without reducing calories is not sufficient for weight loss. However, reducing dietary fat, along with reducing dietary carbohydrates, can facilitate caloric reduction. Evidence Category A. A diet that is individually planned to help create a deficit of 500 to 1,000 kcal/day should be an intregal part of any program aimed at achieving a weight loss of 1 to 2 lb/week. Evidence Category A.

2. Physical Activity

Effects of Physical Activity on Weight Loss Twenty-three RCT articles were reviewed to determine the effect of physical activity on weight loss, abdominal fat (measured by waist circumference), and changes in cardiorespiratory fitness (VO2 max). Thirteen of these articles were accepted for inclusion in these guidelines. A review of these articles reveals strong evidence that physical activity alone, i.e., aerobic exercise, in obese adults results in modest weight loss and that physical activity in overweight and obeseadults increases cardiorespiratory fitness, independent of weight loss. Randomized trials suggest that increased physical activity in overweight and obese adults reduces abdominal fat only modestly or not at all, and that regular physical activity independently reduces the risk for CVD. The panel’s recommendation on physical activity is based on the evidence from these 13 articles:

Physical activity is recommended as part of a comprehensive weight loss therapy and weight control program because it: (1) modestly contributes to weight loss in overweight and obese adults (Evidence Category A), (2) may decrease abdominal fat (Evidence Category B), (3) increases cardio respiratory fitness (Evidence Category A), and (4) may help with maintenance of weight loss (Evidence Category C).

Physical activity should be an integral part of weight loss therapy and weight maintenance. Initially, moderate levels of physical activity for 30 to 45 minutes, 3 to 5 days a week, should be encouraged. All adults should set a long-term goal to accumulate at least 30 minutes or more of moderate intensity physical activity on most, and preferably all, days of the week. Evidence Category B.

3. Effects of Physical Activity and Diet on Weight Loss (Combined Therapy)

Twenty-three RCT articles were reviewed to determine the effects on body weight of a combination of a reduced-calorie diet with increased physical activity. Fifteen of these articles were accepted for inclusion in the guidelines. These articles contain strong evidence that the combination of a reduced-calorie diet and increased physical activity produces greater weight loss than diet alone or physical activity alone, and that the combination of diet and physical activity improves cardio respiratory fitness as measured by VO2 max in overweight and obese adults when compared to diet alone. The combined effect of a reduced calorie diet and increased physical activity seemingly produced modestly greater reductions in abdominal fat than either diet alone or physical activity alone, although it has not been shown to be independent of weight loss. The panel’s following recommendations are based on the evidence from these articles:

 The combination of a reduced calorie diet and increased physical activity is recommended since it produces weight loss that may also result in decreases in abdominal fat and increases in cardio respiratory fitness. Evidence Category A.

 4. Behavior Therapy

Thirty-six RCTs were reviewed to evaluate whether behavior therapy provides additional benefit beyond other weight loss approaches, as well as to compare various behavioral techniques. Of the 36 RCTs reviewed, 22 were accepted. These RCTs strongly indicate that behavioral strategies to reinforce changes in diet and physical activity in obese adults produce weight loss in the range of 10 percent over 4 months to 1 year. In addition, no one behavior therapy appeared superior to any other in its effect on weight loss; multimodal strategies appear to work best and those interventions with the greatest intensity appear to be associated with the greatest weight loss. Long-term follow-up of patients undergoing behavior therapy shows a return to baseline weight for the great majority of subjects in the absence of continued behavioral intervention. Randomized trials suggest that behavior therapy, when used in combination with other weight loss approaches, provides additional benefits in assisting patients to lose weight short-term, i.e., 1 year (no additional benefits are found at 3 to 5 years). The panel found little evidence on the effect of behavior therapy on cardio respiratory fitness. Evidence from these articles provided the basis for the following recommendation:

Practitioners need to 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. Evidence Category D.

 5. Summary of Lifestyle Therapy

 There is strong evidence that combined interventions of an LCD, increased physical activity, and behavior therapy provide the most successful therapy for weight loss and weight maintenance. The panel makes the following recommendation:

 Weight loss and weight maintenance therapy should employ the combination of LCDs, increased physical activity, and behavior therapy. Evidence Category A.

 6. Pharmacotherapy

A review of 44 pharmacotherapy RCT articles provides strong evidence that pharmacological therapy (which has generally been studied along with lifestyle modification, including diet and physical activity) using dexfenfluramine, sibutramine, orlistat, or phentermine/fenfluramine results in weight loss in obese adults when used for 6 months to 1 year. Strong evidence also indicates that appropriate weight loss drugs can augment diet, physical activity, and behavior therapy in weight loss. Adverse side effects from the use of weight loss drugs have been observed in patients. As a result of the observed association of valvular heart disease in patients taking fenfluramine and dexfenfluramine alone or in combination, these drugs have been withdrawn from the market.

Weight loss drugs approved by the FDA for long-term use may be useful as an adjunct to diet and physical activity for patients with a BMI of 30 with no concomitant obesity-related risk factors or diseases, as well as for patients with a BMI of  27 with concomitant risk factors or diseases; moreover, using weight loss drugs singly (not in combination) and starting with the lowest effective doses can decrease the likelihood of adverse effects. Based on this evidence, the panel makes the following recommendation:

Weight loss drugs approved by the FDA may be used as part of a comprehensive weight loss program, including dietary therapy and physical activity for patients with a BMI of  30 with no concomitant obesity-related risk factors or diseases, and for patients with a BMI of  27 with concomitant obesity-related risk factors or diseases. Weight loss drugs should never be used without concomitant lifestyle modifications. Continual assessment of drug therapy for efficacy and safety is necessary. If the drug is efficacious in helping the patient to lose and/or maintain weight loss and there are no serious adverse effects, it can be continued. If not, it should be discontinued. Evidence Category B.

 7. Weight Loss Surgery

The panel reviewed 14 RCTs that examined the effect of surgical procedures on weight loss; 8 were deemed appropriate. All of the studies included individuals who had a BMI of 40 kg/m2 or above, or a BMI of 35 to 40 kg/m2 with comorbidity. These trials provide strong evidence that surgical interventions in adults with clinically severe obesity, i.e., BMIs 40 or 35 with comorbid conditions, result in substantial weight loss, and suggestive evidence that lifelong medical surveillance after surgery is necessary. Therefore, the panel makes the following recommendation:

Weight loss surgery is an option for carefully selected patients with clinically severe obesity (BMI  40 or  35 with comorbid conditions) when less invasive methods of weight loss have failed and the patient is at high risk for obesity-associated morbidity or mortality. Evidence Category B.

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