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Obesity Losing Weight and Keeping It Off


Regardless of what the obese state represents in terms of altered metabolic and hormonal function, obesity is above all a psychological or, perhaps more accurately, a behavioral disorder. Eating is a behavior, and the two most logical and direct ways of losing weight and keeping it off, a sensible diet and moderate exercise, represent, for obese persons, a challenge to fundamentally alter how they should live the rest of their lives.

This course will not ignore the role of drugs (and even surgery) in helping patients to lose weight, but it will focus on the many less drastic strategies available that can make permanent weight loss a reality. For this to occur, the patient with the physician’s active aid and encouragement first must come to understand how being obese can contribute to serious disorders and even shorten life. The motivated patient then will learn how to diet properly (that is, gradually, and by eating foods that are satisfying), and how regular exercise can itself be a strong motivator.

Most importantly, the formerly obese patient will learn how carefully considered changes in life style, attitudes, and relationships with spouse, family, and friends can ensure that weight loss will endure. No weight control effort is complete unless the patient learns how to cope better with the stresses of modern life, and how to prevent or, if necessary, deal effectively with relapses. The recently recognized, and highly publicized, adverse effects of the popular fen-phen regimen, culminating in withdrawal of these drugs from the market, reinforce even more strongly the primacy of behavioral change in the management of obesity.

Obesity: How and Why It Develops

The “equation” of energy balance has two sides. Obesity management long has focused on the caloric consumption side of the equation, and largely ignored caloric expenditure. Recent research has cast light on the critical role played by defective thermogenesis (temperature control) and too little physical activity, both in initiating and perpetuating the obese state. For a majority of adults, body weight remains quite stable from month to month and year to year. This “set point” may be genetically conditioned, and in obese persons is “set” too high.

From two-thirds to three-fourths of obese individuals attain this status only as adults. When obesity does develop before age 35-40 years, the risks to health are especially great. Very often obesity can be related to particular life events: a change in work, life style, or psychological state. Physiological factors such as pregnancy, menopause, or drug treatment may also dispose to obesity.

Definition and Frequency

Obesity is the accumulation of excessive body fat. One in every three Americans may be seriously overweight. A common definition of clinical obesity is a body weight 30% above the ideal, or 20% above ideal if weight- related disease is present.

The quantitative measure of obesity is the BMI, or body mass index, a measure relating body weight to height. If a BMI table is not available, a hand-held calculator rapidly gives the result: multiply body weight in pounds by 700, and divide the result by the square of the height in inches. A seriously overweight individual will have a BMI more than 30 (or 27 if there is either a personal or family history of obesity- related illness). More simply, a person who is 25 pounds or more overweight on a simple weight/height chart begins to incur the health risks of obesity. Measurements of limb circumference and skin-fold thickness are commonly used in research, but are not very practical in everyday clinical practice.

Of course, many persons who fail to meet clinical criteria of obesity nevertheless consider themselves to be “fat,” and may feel compelled to lose weight. The concept of “optimal” weight has proved elusive. In our culture, what is viewed as cosmetically acceptable or attractive may well be the key to how one’s body weight fits one’s self image. Within limits, self-acceptance can be a legitimate factor when a person is considering whether to try losing weight.

Overeating Isn’t the Whole Story: Basic Metabolic Concepts

It is taken for granted that deficient expenditure of energy is a key factor in obesity. Rather than being utilized to a normal extent, calories go unburned and are stored as adipose tissue (fat). Because obesity is the expression of an imbalance between calorie intake and energy expenditure, it stands to reason that increased physical activity is as logical a step as controlling food intake for preventing or treating obesity. A convenient way of thinking about this relationship is the formula:

Change in energy stores = Energy intake ~ Energy expenditure

On a day-to-day basis, energy balance is maintained chiefly by varying food intake in response to energy expenditure. If, however, there is a major change in energy intake, body weight will change and the metabolic rate will increase or decrease accordingly. So, depending on circumstances, energy intake can balance energy expenditure or vice versa.

In most sedentary adults, resting metabolic rate (RMR) accounts for 60% to 70% of energy expenditure. Another 10% is explained by the thermic effect of food (“burning calories”). Physical activity is the final, and most variable factor in daily energy expenditure. RMR correlates with the fat-free body mass but, at any given body size or composition, metabolism may differ considerably between individuals. There is convincing evidence, however, that a reduced RMR relative to body size is a risk factor for future weight gain. Age and gender influence the RMR, and there also seems to be a genetic component. Certainly the thermic effect of food in a given individual might help determine a predisposition to obesity, but it is difficult to measure.

It is true that the amount of energy expended in physical activities varies widely, and also that obesity is associated with a sedentary lifestyle. Nonetheless it has proved impossible to precisely define the effect of activity level on the daily energy expenditure.

Hormonal and Lipid Changes: Causes or Effects?

Numerous abnormalities of steroid and polypeptide hormone secretion are described in obese persons. Men have elevated estrogen levels as well as hypogonadotropic hypogonadism, whereas obese women have increased levels of both estradiol and testosterone, and gonadotropin changes like those seen in polycystic ovary syndrome. Reduced levels of sex hormone-binding globulin are found in men and women alike. Also characteristic of both obese men and women are increased levels of serum insulin, and blunted responses of growth hormone, vasopressin, and prolactin to appropriate stimuli. Endorphin levels are increased and not normally suppressible.

Nearly all these abnormalities (but not hyperendorphinemia) are reversible with weight loss, implying that they are not causes of obesity. They may, however, amplify the morbidity associated with being obese. High insulin secretion, for instance, may increase the risk of hypertension, high blood lipid levels, and coronary heart disease. Hyperinsulinemia and insulin resistance (as in type II diabetes) are closely related. High levels of free estradiol may place obese women at increased risk of developing cancer of the breast or endometrium.

Blood lipid levels correlate strongly with most indices of adiposity including the BMI, though not all obese persons have elevated levels of cholesterol or triglycerides. What abnormalities do occur are basically caused by two mechanisms: excessive production of very-low-density lipoprotein (VLDL) triglycerides, and inadequate enzymatic lysis of triglyceride-rich lipoproteins.

Calories, Appetite, and Food Preferences

Fat is the most caloric type of nutrient, containing nine calories per gram compared to four in both protein and carbohydrate. A general recommendation is that no more than 30% of daily calories come from fat. How many calories does a person need? Certainly a large, young, physically active man needs more than a small, elderly, sedentary woman. To approximate (roughly) a person’s daily caloric need, multiply body weight in pounds by 12.

Formerly it was taken for granted that a “sweet tooth” or assorted food cravings led directly to overconsumption of calories and weight gain. It now is clear that there is no common profile of taste responses in obese persons, and that they do not always prefer the same types of food. The fact is that it has proved difficult to link human obesity with an excessive caloric intake. One possibility, however, is that cycles of weight loss and gain make one’s metabolism more efficient, promote fat intake, and enhance fat storage. There is no question that persons who derive much of their energy intake from fat weigh more than those who prefer non-fat foods.

A list of the top ten American foods is headed by white bread and rolls, contributing nearly 10% of total caloric intake. Accounting for 4-6% each are cookies and cake, alcoholic beverages, whole milk, hamburgers, and beefsteaks or roasts. Soft drinks, hot dogs (and related items), and eggs round out the list, leaving room at number 10 for French fries. (Cheese fries seemingly were not a topic of inquiry!).

Are the Genes to Blame?

A common observation: children whose parents are obese themselves tend to weigh too much. With a family history of obesity, the risk of a child following suit goes up by at least 25% and perhaps as much as 40%. One study claimed that, if both parents are overweight, the child has a 70% likelihood of being obese.

One way in which obesity may be, in part, genetically determined is through body shape. The large frame typical of the “endomorph” provides a higher capacity for storage of fat. The metabolic “thermostat” that determines how actively calories are burned may be another genetic component, but the level of metabolism does not in itself explain much individual variance in body weight. (In fact, resting metabolic rate correlates best with the fat-free body mass). Obese children, like adults with a positive family history, tend to have the “hyperplastic” type of obesity characterized by too many fat cells. A markedly obese individual may have as many as 150 billion fat cells, compared to the normal average of 25-35 billion.

Whatever may be the genetic component of obesity, it does not operate through a simple Mendelian mechanism (although single gene effects do account for certain clinical syndromes that include obesity). Hopefully the “obesity genes” soon will be mapped by finding linkage between the obese state and random genetic markers. It seems likely that there are a number of relatively rare genes that exert large effects in particular families.

The High Cost of Obesity

Quite apart from shortening one’s expected life span and contributing importantly to a number of serious disease states (to be discussed in some detail), being fat has certain universal effects that patients find inconvenient, uncomfortable, and embarrassing. One of the earliest expressions of excessive body fat is shortness of breath. This in itself tends to limit activity, compounding what probably already is a sedentary lifestyle. Accumulating abdominal fat makes it increasingly uncomfortable to sit. Even moderate obesity places a strain on the back and legs and can make degenerative arthritis less bearable. The obese are prone to develop complications after surgery. Wounds heal slowly, and infections are more common.

These “everyday” problems that obese persons live with may actually preoccupy them more than their being at increased risk of serious illness such as cardiovascular disease or diabetes. And in a culture that holds thinness in high esteem and disparages obesity, being substantially overweight can have profound emotional and social consequences.

Life May be Shorter

Certainly excessive (or, as it is aptly termed, “morbid”) obesity shortens life, but whether this holds true for the many million Americans who are 20% or more above ideal weight but not morbidly obese is far from certain. One study does purport to show that men aged 35-65 years whose BMI is 28 kg/sq m (mild obesity) or higher are 5-fold likelier to die prematurely. At a BMI of 40, premature deaths rise sharply. Many studies have failed to show a direct correlation between obesity and early death, but there are confounding factors: controlling for the metabolic effects of obesity and for hypertension will underestimate the true association. Another confusing element is lack of physical activity a correlate of obesity and also an independent risk factor for coronary heart disease.

The Morbidity of Obesity

  • CARDIOVASCULAR DISEASE. Diabetes, hypertension, and abnormal blood lipids, all prevalent in the obese, also are recognized as coronary risk factors. The most obese persons average nearly twice the usual risk of death from coronary heart disease. A report from the American Health Foundation claims that this often lethal condition would be reduced by one-fourth if all Americans maintained a healthy body weight. Further, there would be much less heart failure, and 35% fewer strokes. The risk of a fatal stroke goes up directly with the BMI. Young adults who are obese are five times likelier than their normal-weight peers to develop high blood pressure.
  • NON-INSULIN-DEPENDENT DIABETES. Being 15% to 25% overweight is enough to double mortality from diabetes mellitus, and marked obesity increases the risk more than 5-fold.
  • CANCER. Overweight men reportedly have higher rates of colorectal and prostate cancer, while their female counterparts are at increased risk of gynecological and gallbladder malignancies. Whether breast cancer deaths are increased remains an open question; some studies even claim that the risk is lower for obese pre-menopausal women. It should be mentioned that many studies show that lean persons are more prone to develop cancers of the lung, bladder, and stomach.
  • OTHER SEQUELAE. Obesity is a key factor in the sleep apnea/hypoventilation syndrome, and may be its single most important cause. This condition is not at all uncommon, and it can cause early death. The load imposed by excess body fat may hasten the onset of symptomatic osteoarthritis, and burden the patient with more pain and disability. Obesity has been implicated in several other disorders, though perhaps less convincingly: infertility (both male and female); gastroesophageal reflux; complications of venous stasis in the lower extremities; and urinary stress incontinence.

Quality of Life: Being Obese in a Lean World

Negative attitudes toward the obese permeate our culture and are omnipresent, even if expressed only indirectly by overvaluing being thin (“thin is in”). Self-esteem is impaired as a result, and even depression may develop over time. Women and adolescents are especially vulnerable. Obese persons may suffer discrimination at their workplace (or in acquiring work); are less likely to be admitted to a high-ranking college; and may even have trouble renting. They are widely disparaged as potential marital partners. All this may arise from a deep-seated assumption that allowing oneself to become, and remain, obese is basically a moral failing (a “lack of willpower”).

Dollar Costs

In 1990, preventing obesity in the U.S. might have saved no less than $46 billion nearly 7% of total health care expenditures. Most goes to pay the direct costs of comorbidity and physician visits, but the indirect costs of time lost from work and unpaid tax revenues are substantial. Even today, few insurance providers cover a meaningful amount of the expense for treating obesity. Americans spend an estimated $33 billion each year on diet foods, weight loss programs, special products that promise to “melt it off,” and the like. Both abdominoplasty (the “tummy tuck”) and liposuction continue to gain in popularity.

Evaluating the Patient and Setting Goals

Many patients who present to physicians with the need to lose weight have tried one or more commercial programs. Weight Watchers was the first and is still the largest. Attrition rates in these programs, even when conducted under medical supervision, remain very high. The obese patient must understand and accept that weight management is not a one-time or episodic proposition, but instead will be a lifelong challenge. An Obese Personality?

One might expect most seriously obese people to be overtly disturbed because they have great difficulty maintaining a positive self-image. Surprisingly, however, population studies in America and also in Britain have seldom found significant differences in psychological function between obese and normal-weight individuals, whether children or adults. At the same time, a significant minority of very obese persons do report substantial psychological distress. The widely accepted concept of the “obese personality” an outwardly carefree and even jolly individual who harbors feelings of inferiority and is very passive-dependent was really a psychoanalytic formulation and in fact cannot be objectively confirmed; it is a cliché. Obesity is a very heterogeneous disorder, and personality styles are as diverse as in those of average body weight.

Setting Goals

The general basis for treating obesity could not be more simple: reduce energy intake below energy output. All treatments attempt to achieve this goal, though they may do so in different ways. An “optimal” body weight must be optimal for a particular purpose, such as lowering high blood pressure. The key is to relate a particular obesity-related risk to the BMI, and to monitor how the risk declines as body weight declines. The focus on aggressive weight loss, much in favor in past decades, has given way to a doctrine of moderation.

Nearly all patients who seek weight reduction have decided on a goal weight, and this aspiration should by no means be ignored. At a certain point, or even at the outset in some cases, maintaining stable body weight may be a reasonable goal. It obviously is inappropriate to suggest drastic measures when cosmetic motivations prevail in a person (often a woman) who is not in fact substantially overweight. A commonly proposed goal is to lose one to two pounds a week until the BMI reaches 30 kg/sq m (or 25 kg/sq m for a younger person).

In seeking to match treatment to the patient, two situations may arise:

  • If the patient follows a sound dietary plan and loses weight at an appropriate rate, the physician need merely continue providing encouragement as the target weight is approached.
  • If the patient fails to lose weight rapidly enough despite professed adherence to a good diet, energy output may be measured by calorimetry to persuade the patient that better compliance is needed. Or, the patient may acknowledge that the diet is too strict and is “not worth it.” In this case the physician may suggest behavioral procedures, specific forms of social support, or more aggressive measures such as pharmacotherapy or even gastric stapling, in an attempt to tip the balance.

The Payoff: Lose Weight and Gain Health

When the patient asks “Why should I lose weight?” the physician can supply numerous answers, any one of which may prove highly motivating:

  • Overweight persons who lose more than 10 pounds probably cut their risk of developing type II diabetes by at least half. If diabetes has already developed, weight loss helps control hyperglycemia, lessens insulin resistance, and enhances carbohydrate tolerance. These effects endure as long as body weight remains under control.
  • Even modest weight loss can lessen hypertension without the need for specific anti-hypertensive measures (and, in the process, avoid side-effects from these drugs). A 20% weight reduction may normalize the blood pressure.
  • The onset of symptomatic osteoarthritis may be forestalled. More to the patient’s interest, existing symptoms may diminish significantly with the body weight.
  • The decline in HDL cholesterol (the “good” type) that typifies the obese state is reversed by weight loss. Loss of as little as 5% can improve the total cholesterol and, more importantly, the LDL:HDL ratio. Elevated plasma triglycerides also will decline. These changes translate into a lower risk of coronary heart disease.
  • Possibly superseding all this good news is that a successful effort to lose weight will reliably restore to the formerly obese patient a good measure of self-esteem. Relationships with family, friends, and fellow workers may become less strained. The patient will feel better physically and mentally, will be more comfortable, and can undertake activities undreamt of before.

[Note: There are reports that rapid weight loss on a strict diet raises the risk of gallstones forming. This need not happen, however, as long as the diet contains adequate amounts of protein (14 g) and fat (10 g) at least once each day to promote contraction of the gallbladder. Also, weight loss should not exceed 2% per week.]

The Psychology of Obesity: Effective Behavioral Interventions

Not all obese patients are strongly motivated to lose weight, but motivation may be acquired along with the specific behavioral techniques needed to actually reduce caloric intake. Both are key elements: the patient must want to lose weight, but without the requisite behavioral skills will be unable to do so. A major reason why attempts to lose weight fail as often as they do may well be that patients especially those in commercial programs are treated in a routinized manner rather than taking into account their individual personalities, behavior, and motivation.

Though to many it may seem too obvious to mention, taking a positive attitude towards the formidable task of learning to eat less is vitally important. The long-time smoker should think not of “stopping” a negative approach (nobody likes being told to stop doing something), but rather of becoming a nonsmoker. Similarly, the obese patient should focus not merely on “cutting down,” but on becoming a new person, one whose normal body weight will promote good health and longevity.

Compulsive Eating: The Addiction Model of Obesity

In many respects obese persons do tend to resemble those dependent on psychoactive substances: they may eat in inappropriate ways at odd times; feel that they cannot stop; will abstain temporarily; and often keep overeating even if serious physical disease intervenes. Most persuasive of all is that overeating is relied on to cope with the demands of daily life. At the same time, there is no strong evidence for tolerance or withdrawal symptoms. Moreover, an addiction model does not fit with the fact that most compulsive eaters are extremely disturbed by their condition.

Some believe that, even if obesity is not truly a food addiction, treatment based on this model might be effective. Others, however, have found it most productive to de-emphasize abstinence, so as not to magnify feelings of deprivation and trigger a vicious cycle of restraint and disinhibition.

State-of-the-Art Behavioral Management

Behavioral treatment a rather unwieldy term really means finding ways to change one’s daily habits, responses, and relationships in ways that will make it easier to become less heavy and stay that way. The key is to identify the antecedents of particular behaviors and their consequences.

Key components of any behavioral program:

  • A group setting – Typically about 10 individuals meet for 1-2 hours each week over 12 to 20 weeks. Often booster sessions are available. Even a small cash deposit can enhance attendance!
  • Self-monitoring – One must become aware of one’s behavior in order to change it. At the start, a willingness to do this is a good indicator of motivational level. As treatment continues, self-monitoring will show whether, and how, a person is changing; which behaviors are especially problematic; and which techniques are most useful.
  • Stimulus control – Eating behavior is strongly influenced by external cues such as the time of day, the physical setting, and the sight of food. Once these cues are recognized it becomes much easier to reduce exposure to food.
  • Reinforcement – Self-monitoring itself can be a source of great satisfaction, and relatives and friends can powerfully reinforce positive behaviors. Rewards (buying a new outfit) are wonderful for morale.
  • Nutrition – Long ignored in behavioral programs, nutritional information will help patients plan a diet to lose weight and also enhance overall health. The prospect of lowering blood pressure and preventing a heart attack can be most enticing.
  • Exercise – Behavioral principles may help patients begin, and maintain, a regular exercise regimen. At the start, it isn’t necessary to run 5 miles a day. Walk up stairs; park farther from the store.
  • Cognitive change – Today behavioral programs routinely try to modify patient attitudes and beliefs about eating and obesity.

Seven Lifestyle Techniques

1. keep an eating diary

2. become aware of and avoid automatic eating

3. identify those things that trigger eating

4. weigh yourself regularly

5. follow a pre-planned eating schedule

6. leave something on your plate

7. put the utensil down between bites

Seven Attitudinal Changes

1. distinguish between “real” hunger and a craving to eat

2. set a realistic weight-loss goal; don’t try for perfection

3. try not to fantasize about food or achieving “ideal” weight

4. focus on behavior not body weight itself

5. be vigilant to high-risk situations and settings

6. don’t be too hard on yourself; don’t confuse a lapse with a relapse

7. when you feel the urge to eat, wait it out

Seven Relational Tips

1. select a partner in your group and tell him (her) how to help you

2. make specific and positive requests of your partner

3. shop with your partner; have your partner shop for you

4. reward your partner

5. exercise with your partner

6. tell your relatives and friends how they can aid your efforts

7. don’t yield to pressure to eat more

Note: Those closest to you, often without intending to, may try to sabotage your efforts. They might be jealous, or may want to keep you “the way you are.” Do not get angry; instead, explain why and how you are trying to lose weight. Help them to understand what you are going through.

Seven More Lifestyle Techniques

1. eat in one place and do nothing else while eating

2. shop when you’re not hungry and avoid ready-to-eat foods

3. put healthy foods out and keep problem foods out of sight (and mind)

4. remove serving dishes from the table

5. anticipate high-risk situations and special events

6. eat often away from home and with others

7. leave the table when you’re done

Dealing With Stress

Without question life stress has a disinhibiting effect on eating behavior. Those who find themselves in a weight control program are most vulnerable of all. Stress management does not mean psychotherapy. Although exploring the psychodynamics underlying obesity may be in order for an occasional patient, many feel that short-term attempts to gain deep insight into stressors and how they promote overeating may actually be counterproductive.

If possible, the patient should learn to anticipate stress; avoid situations where stress is likely to be experienced; manipulate high-risk settings (perhaps by leaving); and respond in some way other than eating. Most important of all is to learn a relaxation response. Techniques are not lacking: medication; yoga; Zen; biofeedback; and the popular method of progressive muscle relaxation (PMR). All these techniques have two essential components: focusing on a repeated word, phrase, sound, or image; and rejecting intrusive thoughts. PMR in particular is easy to learn (especially in a group setting), and can be used anywhere including the most public settings. The more it is practiced, the more effective it becomes.

The Obese Child

The number of obese children in the U.S. is rising dramatically; many health officials speak of a public health crisis. Obese children face the same health risks as adults and, most discouragingly, frequently become obese adults.

Overweight children are not necessarily overeating. Much of what they do eat is calorie-rich, so that a child needn’t consume huge amounts of food (and high-cal beverages) to gain undue weight. The average teenager drinks 65 gallons of soft drinks each year. Inactivity is a major cause of obesity in children. Many blame TV for today’s children being increasingly inactive.

Treatment is the family’s business. Parents must not, at all costs, make fun of their overweight child, but rather should promote healthy eating and an active lifestyle in ways that are fun and inviting. Many active pursuits are better than one, and some of them at least should be noncompetitive. School and community activity programs should be readily available.

A brochure, Helping Your Overweight Child, may be obtained from the International Food Information Council Foundation, P.O. Box 65708, Washington, D.C. 20035.

Getting It Off


Calories do count, particularly fat calories, which are strongly implicated in obesity. An emphasis on lowering fat intake (rather than calories per se) will call for an average daily intake of fewer than 1200 kcal. Too rapid a reduction in weight may have adverse effects in the long term. Typically, for instance, rapid-weight-loss plans are low in carbohydrate, and this can result in marked diuresis, dehydration, and even ketosis. A moderate diet lowers the energy intake below the maintenance level but provides more than 800 kcal per day. Typically body weight will fall by 1% per week. The goal should be to lose weight at a moderate rate by reducing caloric intake in a nutritionally balanced manner.

Behaviorally based programs usually attempt weight loss of one to two pounds per week. More rapid loss is possible by increasing the rate of loss, but maintenance becomes more of a problem. Weight loss also may be maximized by prolonging the duration of treatment. Compared to the basic 12-week program, a 16-week plan increases average weight loss from 8-11 pounds to 20 pounds or more. Financial incentives deserve more attention. Patients who deposit a sum of money and get it back incrementally as they lose weight have averaged losses up to 30% greater than when the same program is used without incentives.

Good general advice for the moderate dieter is to limit daily calories to 1200; to limit fat to 30% of total calories; and to take vitamins in recommended doses.

Commercial Programs

If a patient is interested in a community-based diet program, the clinician can help in selecting one that is likeliest to have the desired outcome without incurring undue health risks.

Diet Center prescribes a diet plan and micronutrient supplements. Carbohydrate and alcohol are restricted. Patients take three meals and two snacks a day.

Weight Watchers is based on a balanced, calorie-restricted diet, behavior modification, and regular exercise. Users can choose their caloric intake within the range of 1000-1600 kcal/day. Food products are available but not heavily promoted.

Nutri/System and Jenny Craig both rely on packaged foods purchased from the centers. Exercise planning and behavior modification are offered, but counsellors are not always trained professionals. The diet provides 1000 to 1700 kcal per day with reduced levels of fat, cholesterol, and sodium.

Slim-Fast is also a packaged food program, but the chief product is a liquid formula marketed directly to consumers at stores rather than special outlets. Diet instructions and sample menus are provided.

Take Off Pounds Sensiby (TOPS) is a non-profit organization that collects low monthly dues and advises medical supervision. Members attend meetings that provide social support. There is no specific diet.

Overeaters Anonymous (OA) is another nonprofit, self-help group whose 12-step program is modeled after that of AA, but prescribes no specific diet.

It has to taste good.

A highly motivated patient will put up with virtually anything to lose weight fast, but when it comes to maintaining that loss, palatability becomes a key concept. How food tastes, smells, feels (its texture), and appears, all count. The importance of a varied diet cannot be overstated. Eating basically is, and should be, pleasurable. If an obese individual finds that a weight-loss diet can be satisfying, compliance becomes far likelier. Most people like some sweet foods, and there is little direct evidence that those who are obese eat too much of them. Here are a number of practical tips that patients will appreciate.

A highly motivated patient will put up with virtually anything to lose weight fast, but when it comes to maintaining that loss, palatability becomes a key concept. How food tastes, smells, feels (its texture), and appears, all count. The importance of a varied diet cannot be overstated. Eating basically is, and should be, pleasurable. If an obese individual finds that a weight-loss diet can be satisfying, compliance becomes far likelier. Most people like some sweet foods, and there is little direct evidence that those who are obese eat too much of them. Here are a number of practical tips that patients will appreciate.

When shopping:

Read labels and buy products with little cholesterol and saturated fat.

Buy lean meats, fish, and poultry. Dried beans and peas are good protein sources.

Consume only low-fat dairy products, including skim or 1% milk.

Eat abundant fresh fruits and vegetables as well as breads and cereals for fiber.

Sherbets and ices are a good choice for dessert.

When preparing food:

Broil, roast, bake, or microwave meats to eliminate much of the fat.

When making stews and other meat- or poultry-based dishes, refrigerate them and skim off the hardened fat before serving.

Steam vegetables rather than sautéing them in butter or oil.

Remove the skin from chicken and other poultry.

When snacking:

A cup of vegetable soup makes an excellent snack, as do raw vegetables, popcorn, cereal, and fresh fruit.

Buying reduced-fat snacks may not be the answer. While they do contain at least 25% less fat than the regular version, you may eat so much that you take in appreciable fat.

When eating out:

Order simple foods such as grilled meat; a baked potato (without butter); salad with dressing on the side; and a vegetable with lemon juice.

Order meat, fish, or poultry broiled (and with the skin removed), not fried. Ask for the sauce to be omitted or, if desired, brought on the side.

Consider sharing an entree with a companion, or leaving some to take home.

The Very-Low-Calorie Diet (VLCD)

The VLCD has been with us for more than six decades, but for some time these diets were deficient in micronutrients as well as vitamins and minerals. Today the VLCD, providing 400 to 800 kcal per day for 12-16 weeks, is regarded as safe when used responsibly. The optimal mix of macronutrients and the proper roles of fat and carbohydrate remain uncertain, however. Only when a conventional 1200-kcal diet has failed should a VLCD be considered. The patient must commit to at least one year in active treatment, which period will include a weight maintenance phase.

Nobody who is less than 30% overweight should receive a VLCD. Persons with severe health risks from obesity and those seeking rapid weight loss before surgery are the best candidates. A VLCD is not permissible for cosmetic reasons. Infants and children less than 14 years of age, those over age 65, and pregnant or lactating women should not be placed on a VLCD. Contraindications include porphyria, gout, recent myocardial infarction, a cardiac conduction disorder, a history of cerebrovascular or hepatorenal disease, type I diabetes, and significant psychiatric disorder. Any evidence or history of an addictive or eating disorder also rules out a VLCD.

In the U.S., nearly all patients take a VLCD in the form of a powdered-protein formula, which is mixed with water and taken 3 to 5 times daily. Patients generally should lose 1-2 kg (2-4 lb)

per week when taking a VLCD. Three-fourths of the weight loss should represent fat mass. Perhaps half of all patients will drop out, and an estimated 30% of those who do complete the program will maintain weight loss for 18 months or longer. On average, a patient will maintain half to two-thirds of the initial weight loss for 18-24 months. Behavior modification and an exercise program are important adjuncts to the VLCD.

Health benefits often are virtually immediate and dramatic. Improved glycemic control or the rapid lowering of elevated blood pressure will greatly motivate a patient to continue on the diet and to maintain weight loss. Patients tend not to feel unduly hungry after the first few days, but may experience weakness and fatigue, dizziness, altered bowel habits, nausea, or cold intolerance, all of which tend to be transient.

Predicting the Response to Dietary Therapy

Initial body weight may be the best predictor of weight loss; heavier patients tend to lose more weight (to a modest degree). A history of binge eating reported by 25% to 70% of those participating in weight reduction programs seems to predict failure of either a conventional diet or a VLCD. Patients who, by their own account, are experiencing unsettling and stressful life events probably should wait for a more propitious time to begin a diet, as dieting itself is stressful. Those who lose weight very slowly are relatively likely to become discouraged. Patients who don’t like what they see when they look at the scale are good candidates for additional counseling.


At the time this is being written (October 1997), the role of drugs in managing obesity has changed rather dramatically! Recognition that the popular drug combination fen-phen may cause serious cardiac valve disease, particularly in previously healthy women, has led to its withdrawal from the market.

Perhaps it should not have taken this. Adrenergic agents such as phentermine (the phen in fen-phen) tend to increase blood pressure and may dispose to cardiac arrhythmia in susceptible patients. They also may place patients having undiagnosed glaucoma or hyperthyroidism at increased risk. Fenfluramine (the fen component) and its sister drug dexfenfluramine (Redux), which alter serotoninergic transmission, were previously known to carry a risk of primary pulmonary hypertension, a frequently fatal condition. There is evidence from animal studies than fenfluramine and related drugs may critically damage brain cells. Occasional patients taking fen-phen have noted short-term memory loss.

Fen-phen became increasingly popular after a series of studies by Weintraub and colleagues claimed that, when added to dietary treatment, exercise, and behavior modification, additional weight loss was achieved. Not much added weight loss could, however, be ascribed to the drug component (perhaps five or six pounds beyond that achieved with a diet), and it was rapidly regained when fen-phen was stopped. The investigators used drugs only in those meeting conventional criteria for true obesity. Without a doubt, many of the estimated 18 million prescriptions written in 1996 for fen-phen went to those seeking cosmetic weight loss.

Many drugs are susceptible of abuse, but anorexiants are a prime example of commercial abuse. Many physicians with little or no training or expertise in obesity treatment established fen-phen treatment programs that promised a long-term cure. These drugs were intensively promoted in magazines, supermarket tabloids, and on TV. Purveyors have offered a discounted initial visit. Lip service sometimes was paid to adjunctive measures, but they were not mandatory. Some sources provided drugs to all who wanted them. Finally, some commercial weight loss programs began prescribing appetite suppressants. While approved only for short-term use, this restriction very often has been ignored.

Responsible investigators have always insisted that drugs be a part of obesity treatment only when the potential benefit unambiguously outweighs the risks. For the most part, this means that drug treatment should be time-limited, and reserved for substantially obese persons who have serious obesity-related health risks.

The experience with fen-phen hopefully has been a cautionary one, yet many “diet doctors” today are not waiting for the next drug to be approved, but are contriving combinations of drugs already on the market (phentermine combined with Prozac as “phen-pro,” or with the antidepressant trazodone as “phen-traz,” are examples). One would hope that what has happened will permanently discourage obese persons (and their physicians) from relying on drugs to lose weight, especially considering that the obese may in fact have some addictive personality features. Rather, management should focus even more sharply on a moderate diet, a healthy lifestyle, and whatever behavior modification is needed to ensure compliance with these measures.


Liposuction is a cosmetic procedure that may enhance one’s appearance when there are massive localized collections of fat.

Gastrointestinal bypass procedures, formerly used as a means of dealing with morbid obesity, often involved excluding 90% of the small bowel. The jejunoileal bypass was a common version. This approach came into disfavor in the 1970s because malabsorption of vital nutrients led to severe nutritional deficiencies, diarrhea, and serious metabolic problems. In time a majority of patients required revision or reversal of their surgery.

Gastric restriction procedures today are the preferred operative approach to morbidly obese patients (those weighing double their optimal weight or with a BMI greater than 40 kg/sq m). In the vertical banded gastroplasty, the stomach is “stapled” to lower its capacity to about 15 ml and a small silastic ring sometimes is placed to keep the stomach from “stretching.” Eating more than a small amount of food will distend the proximal gastric pouch and produce a sense of fullness or satiety. Continuing to eat likely will result in nausea, vomiting, or pain. Reported mortality rates are 1% to 2% and a number of complications may develop, including outlet obstruction requiring revision surgery; clotting of leg or pulmonary veins; and protein calorie malnutrition. On average, patients lose 50 to 100 pounds, and more than half will maintain the loss for 5 years.

Keeping It Off

Beyond its actual effect in promoting energy expenditure, a regular exercise regimen signifies a vital part of a “new lifestyle,” and as such can be an invaluable part of a life-long weight reduction effort. Weight reduction is indeed an indefinite commitment. This section will outline elements of the “new lifestyle,” and discuss ways of predicting those formerly obese patients who are most likely to remain at lower body weight. Also discussed will be relapses and how to prevent them.


Would you like to be able to advise your patients to do one thing that will:

  • burn calories
  • increase metabolic rate (which tends to decline as body weight decreases)
  • maintain muscle mass (which also tends to diminish as body weight declines)
  • reduce stress
  • make them feel good

Then teach them encourage them exhort them to adopt a regular exercise regimen. Exercising regularly will not assure that they will maintain weight loss, but it certainly helps. Even three weekly half-hour exercise sessions will increase resting metabolic rate and permit one to eat more calories while not gaining weight.

It is not uncommon for persons who have lost substantial weight to first regain it when their customary exercise is limited for any reason.

What It Does

Anaerobic exercise such as weight-lifting does not burn many calories, but it does increase muscle mass, and this in turn increases the resting metabolic rate a key determinant of the total calories needed to maintain body weight. If caloric consumption remains the same, anaerobic activity will lower the proportion of body fat.

Aerobic exercise, which requires continuous movement of some sort and increases the respiratory rate, significantly raises caloric requirements and also builds up muscle mass (to a lesser degree). A 180-pound man who walks briskly for 30 minutes each day will burn about 200 extra calories. This may not seem like much, as one pound of body fat represents 3500 calories, but over a year it adds up to more than 20 pounds of weight loss.

Diabetic patients benefit directly from exercise; it increases insulin sensitivity independently of weight loss. Moreover, regular exercise seems to help control elevated blood pressure even if further weight loss does not occur. Exercise improves the lipid profile, enhances myocardial vascularity, and enhances exercise tolerance. Perhaps most important is the psychological benefit conferred by regular exercise. Increasing exercise tolerance translates into a higher level of everyday activity. Formerly obese persons who can be more active and feel better as a result will be highly inclined to maintain this state of affairs by continuing to control their caloric intake.

How to Go About It: Seven Tips on Exercising:

  • Keep an exercise diary.
  • Find ways to exert yourself more in your everyday home life and at work.
  • Try different activities: jogging, cycling, aerobic dance.
  • Don’t disparage simple walking; walk as much as you can, and in a pleasurable setting if possible.
  • At some point, and with the knowledge and approval of your healthcare provider, choose a programmed activity, get into it gradually, and stick with it.
  • Always warm up and cool down, gradually.

Maintaining Lower Body Weight

Those who do manage to lose excess body weight have lower energy needs, so that they will rapidly regain their lost weight if they resume eating as they did before. It may be harder for the formerly obese person to detect weight that is going back on, even as much as 10 pounds, after losing considerably more than this. So, awareness is a key to keeping it off. Patients should use the scale regularly and not take anything for granted.

For those given a VLCD, it is very helpful to anticipate the “re-feeding” phase at least a few weeks in advance. The dieter should know that adherence to the prescribed re-feeding diet will help prevent unwanted side-effects. It probably is a good idea to limit food choices for a few weeks. The end of a diet period is an ideal time for instructing patients in the principles of sound nutrition.

Winners and Losers

Maintenance of weight loss is not a static phase of management, as it often is thought to be, but rather an active phase in which one must consolidate the gains and vigilantly guard against relapse. While perhaps only a handful of patients will maintain their full weight loss after 3-5 years, a significant additional fraction will still be 10-12 pounds lighter than when they began.

The two critical treatment factors are continued care and exercise. Regular contacts between patient and practitioner in the first post-treatment year predict the successful maintenance of weight loss. An alternative: bi-weekly group sessions where patients review the diet and exercise diaries they still are keeping, and discuss any problems that arise. The effect of exercise is partly metabolic, but to an important degree it helps by enhancing the patient’s mood and self-esteem.

The winners in the effort to maintain weight loss:

  • continue eating a low-fat diet based on foods they like.
  • exercise regularly.
  • faithfully monitor their body weight and food intake.
  • use their new-found problem-solving skills to cope with life stresses.
  • in general, are willing to take control of and responsibility for their lives.

The losers confront more negative life events, and are likelier to be part of a dysfunctional family. Lack of a structured support system bodes ill (social support often means a self-help group).

Patients entering the maintenance phase often are “gung ho,” but the concept of gradualism comes into play at this point. Gradually increasing exercise and lowering fat intake will make it easier for the patient the final judge to determine at what body weight he can envision living the rest of his life. It is at this time, also, that the patient will come to recognize that permanent weight reduction will require a lifelong commitment.

Relapses: How to Prevent Them

Many physicians have heard that weight reduction fails to endure 95% of the time. This figure comes from a 1959 study by Stunkard and McLaren-Hume, who followed 100 patients after treatment in a hospital nutrition clinic. Only 12% of the patients lost 20 pounds or more, and half of them had regained it a year later. Current data are far less pessimistic. In a number of studies conducted in the past decade, incorporating behavior modification, patients lost an average of 22 pounds after a 16-week treatment period, and had maintained two-thirds of this weight loss when followed up an average of 3 years later. The news for patients given a VLCD plus behavioral treatment is not so good. Many lose an impressive amount of weight, but 60% or more of the loss is regained within 30 months.

Five key steps in preventing relapse:

1. identify high-risk settings and situations

2. learn and use problem-solving skills to avoid or deal with these situations

3. intentionally practice coping with identified high-risk factors

4. with a therapist’s help, develop in advance those cognitive coping strategies that will help overcome a setback

5. encourage patient self-rewards for adhering to the program

Frequent contact with the physician or other therapist will without doubt lessen the chance of relapse. A group setting can provide incentive, often in the form of peer support and encouragement, to continue progressing toward the patient’s target weight. Many patients of faith have recourse to prayer at critical times in their lives; it may help immeasurably.


Hopefully this course has made the all-important point that eating is a behavior and that obesity, ultimately, is a behavioral disorder. Reducing caloric intake and exercising regularly are indispensable tactics for losing weight and maintaining weight control (drugs are not). But to remain effective, they must be grounded on a basic strategy of behavioral modification. Only by understanding why a given individual has become obese will it be possible to help that patient learn how to lose excess body weight and keep it off. An individualized approach and ongoing physician-patient contact are essential if the patient is to maintain a lifelong commitment to losing weight and, as a result, escape the heavy burden of obesity-related morbidity and premature death.

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