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Obesity/Overweight Prevention/Treatment

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Obesity is a contributor to or a cause of chronic medical and/or surgical conditions including diabetes, hypertension, hyperlipidemia, heart disease, stroke, certain cancers, recurrent trauma and arthritis. Here are a few of the more ponderous facts:

  • The apparent rise in the incidence of hypertension and diabetes worldwide is concerning.  Certain populations, non-Hispanic blacks, for instance are at higher risk, but it is getting scary for all of society!
  • "For everyone American who worries about their weight or the weight of their children, there is a stunning prediction....Health experts warn that by the year 2030, a staggering 42% of Americans will officially be obese."  [Ref. Williams,  NBC Nightly News (5/7/2012)]
  • We learn from the Center for Disease Control's (CDC's) Grand Rounds that the more severe the obesity, the greater the chances of morbidity or mortality from these conditions. ["Childhood Obesity in the United States" [Morbidity and Mortality Weekly Report (MMWR) Jan. 21, 2010;60(02):42-46]
  • A long-term study in young adults reveals that the risks for new and/or worsening subclinical coronary artery disease increased by 2%–4% for every additional year of obesity.

"The obesity epidemic is rampant, particularly in children and young adults. However, the consequences of long-term obesity are largely unknown. To find out more, investigators used data from the CARDIA study on 3275 young adults (aged 18–30; 51% women; 46% black) who were nonobese at baseline in 1985–1986 and were examined for the presence and degree of coronary artery calcification (CAC) at least once at years 15, 20, and 25.

At 25 years, 40.4% of participants had developed overall obesity (mean age of onset, 35.4), and 41.0% had developed abdominal obesity (mean age of onset, 37.7). Mean duration of obesity was 13 and 12 years for overall and abdominal obesity, respectively. CAC was present in 27.5% of all participants; in 38.2% of those with overall obesity of more than 20 years' duration; and in 39.3% of those with abdominal obesity of more than 20 years' duration. Rates of CAC increased significantly with increasing duration of obesity (adjusted hazard ratios, 1.02 and 1.03 per additional year of overall and abdominal obesity, respectively), and CAC was more likely to progress over 10 years in obese than in nonobese participants (adjusted odds ratio, 1.04 per additional year of overall or abdominal obesity). The association between obesity and CAC was not affected by race or sex."

Foody JAM. "Duration of Overall and Abdominal Obesity Linked to Coronary Calcification" JAMA's Journal Watch [subscription not required in this quote], posted 8/21/2013 pertaining to her review of Reis JP et al., JAMA 2013 Jul 17; 310:280

  • Trends in such outcomes, however, do not always correlate well with the incidence of obesity. For example, over the past few decades, obesity is identified more often, while mortality rates, especially from coronary heart disease and stroke seem to be decreasing, perhaps through improvements in medical care and public health. 

The following are population-based strategies for the prevention and treatment of obesity/overweight.  But first, let's review how prevention is defined....

Level

Definition

Primary prevention

Primary prevention strategies help avoid the development of disease.[2] Most population-based health promotion activities are primary preventive measures.

Secondary prevention

Secondary prevention strategies attempt to diagnose and treat an existing disease in its early stages before it results in significant morbidity. [3].

Tertiary prevention

These treatments aim to reduce the negative impact of established disease by restoring function and reducing disease-related complications.[4]

Quaternary prevention

This term describes the set of health activities that mitigate or avoid the consequences of unnecessary or excessive interventions in the health system.[5]

 

In this context, and in other words [Wiki]

  • Primary and Secondary Prevention: Those that focus on the bio-psycho-social model and the environment--patient education and health promotion for Primary Prevention and modifying the disease in its early stages as in Secondary (example, the use of Metformin, introduction to aerobic conditioning, even prophylactic lap-bands.
  • Gut bacteria play a far greater role in the lives of humans and animals than previous realized. The synergism between bacteria and our lives begins at or before birth, when "infants are anointed with [bacterial] populations from their mothers.... Babies who are born by cesarean and never make that trip through the birth canal apparently never receive some key bugs from their mothers — possibly including those that help to maintain a healthy body weight. Children born by C-section are more likely to be obese in later life....By the time we reach adulthood, we have developed our own distinct menagerie of bacteria."  The other end of this bacterial synergism [pardon the pun] is fecal or stool transplantation or fecal bacteriotherapy. There are many other examples, but the profound, paradigm-shifting implication is that the microbiome flora may be critical to health and warding off disease. [Kennedy, Pagan. "The Fat Drug." NY Times [last updated  3/8/14]​​​
  • Tertiary Prevention: for those who are already obese and showing signs or symptoms of end-organ disease, there are clinical preventive maintenance medicine strategies and treatment regimes—e.g., from strong medicine plus increasing fruit and vegetable consumption, taking into account labels of caloric density in fast food restaurants, etc.
  • The US Preventive Services Task Force (USPSTF) recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to intensive counseling and behavioral interventions to promote improvements in weight status (grade B recommendation).  [Pediatrics, Feb 2010(125):361-367.]

Video: "Weight Bias in Health Care" on the Rudd Center for Food Policy and Obesity including web-based Continuing Medical Education (CME)]


Online Toolkit

This toolkit, with downloadable files, is designed to help health care providers across a variety of practice settings with easy-to-implement solutions and resources to improve delivery of care for overweight and obese patients.


Positive Association between Comprehensiveness, Intensity of Treatment and Outcome

Obesity treatment can be effective and extend beyond the immediate intervention.

Comprehensive treatment, defined as treatment includes: (a) counseling for healthy diet or even weight loss, (b) counseling for physical activity, and (c) instruction in and support for use of behavioral management techniques to make durable lifestyle (diet and physical activity) changes.

The level of intensity of intervention matters, i.e., twice-weekly hour-long meetings for 6 months and once-weekly hour-long meetings for the following 6 months with a combination of group and individual sessions with a group of multidisciplinary personnel including dieticians, psychologists, trainers, and practitioners in the context of a medical home.

Lower-intensity interventions can used in structured, weight-management efforts in primary care. However, "Payment for multidisciplinary personnel and financial support of group treatment models, telephone and Internet care and mechanisms to support parent-only care interactions, would be critical to allow interventions such as these to be implemented in practice."

It is surprising that the final USPSTF recommendation was limited to screening and treatment only of children older than 6 years of age.  Regardless, pediatricians should continue to screen all children older than 2 years for overweight and obesity by using BMI percentiles and measure weight for length in children younger than 2 years of age.

Hassink SG,  [Wilmington, Delaware] "Treatment: Pediatricians on the Right Track!"  [Commentary] Published online January 18, 2010 Pediatrics Vol. 125 No. 2 February 2010, pp. 387-388 (doi:10.1542/peds.2009-3308)  [Free PDF]

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A realistic view of what one can accomplish in weight management.

"'As clinicians, we celebrate small changes because they often lead to big changes,'said Dr. David Ludwig, director of the Optimal Weight for Life program at Children’s Hospital Boston.  [Yet, such changes alone would] not produce substantial weight loss."

"Why wouldn’t they? The answer lies in biology. A person’s weight remains stable as long as the number of calories consumed doesn’t exceed the amount of calories the body spends, both on exercise and to maintain basic body functions. As the balance between calories going in and calories going out changes, we gain or lose weight.

But bodies don’t gain or lose weight indefinitely. Eventually, a cascade of biological changes kicks in to help the body maintain a new weight. As the JAMA article explains, a person who eats an extra cookie a day will gain some weight, but over time, an increasing proportion of the cookie’s calories also goes to taking care of the extra body weight. Eventually, the body adjusts and stops gaining weight, even if the person continues to eat the cookie.

Similar factors come into play when we skip the extra cookie. We may lose a little weight at first, but soon the body adjusts to the new weight and requires fewer calories.

Regrettably, however, the body is more resistant to weight loss than weight gain. Hormones and brain chemicals that regulate your unconscious drive to eat and how your body responds to exercise can make it even more difficult to lose the weight. You may skip the cookie but unknowingly compensate by eating a bagel later on or an extra serving of pasta at dinner."

"While small steps are unlikely to solve the nation’s obesity crisis, doctors say losing a little weight, eating more heart-healthy foods and increasing exercise can make a meaningful difference in overall health and risks for heart disease and diabetes."

Parker-Pope T.  "In Obesity Epidemic, What’s One Cookie?" March 1, 2010, 5:08 pm — Updated: 11:43 AM

Overweight and obese children who participated in the Mind, Exercise, Nutrition, Do It program, commonly known as MEND— a free, 10-week, after-school weight management course that promotes healthy eating and physical activity among overweight and obese children and their families, experienced significant decreases in waist circumference, reductions in BMI and improvements in blood pressure, recovery heart rate, physical activity level and global self-esteem.

From 2005 to 2007, researchers at the University College London Institute of Child Health conducted a randomized, controlled trial to assess the efficacy of the MEND program.

The MEND intervention involved 18 two-hour sessions during nine weeks. All sessions were conducted by two MEND leaders and one assistant. Eight sessions were devoted to behavior change, eight to nutrition and 16 to physical activity. In addition, a 12-week family swimming pass was issued to all participating families at the end of the program.

The researchers included 116 children aged 8 to 12 years with BMI >98th percentile and randomly assigned them to either participate in intervention or wait six months for intervention. They took measurements at baseline, six and 12 months. Mean attendance was 86%.

At six months, children assigned to the MEND program had a reduced waist circumference z score (–0.37) and a BMI z score that compared with children assigned to wait six months for intervention (–0.24; P<.0001 for both). At 12 months, children in the intervention group had reduced their waist circumference z score by 0.47 and BMI z score by 0.23 (P<.0001 for both).

Data reveal a –4.1-cm difference in waist circumference and a –1.2 difference in BMI between children enrolled in the MEND program and the control group; however, the researchers noted little change in body composition during the study period.

The benefits of the MEND program were sustained for nine months after completion of the program, according to the researchers.

“The MEND program isn’t a miracle pill for obesity, but what this independent study does show is that child weight loss programs that involve the whole family are a scientifically proven and sustainable solution to the child obesity crisis,” Harry MacMillan, chief executive of MEND, said in a press release. “With the recent suspension of obesity drugs, people are starting to wake up to the fact that quick fixes don’t work. These research findings prove that teaching children how to keep fit and eat healthy does work if done in the right way.”

"MEND program deemed effective intervention for childhood obesity." Posted on the Pediatric SuperSite on February 17, 2010

Special Ref., Sacher PM. Obesity. 2010;18:S1-S7