obesity
OBESITY
Obesity is having an excessive amount of body fat in relation to lean body mass that may impair health.
The primary cause is an energy imbalance between calories consumed and expended.
Treatment goals include to lose 5-10% of body weight or 0.5-1 kg (1-2 lb)/week for 6 months and regain of <3 kg in 2 years and sustained reduction of waist circumference of at least 4 cm.
Strategies are aiming for realistic goals and a multidisciplinary approach that is a combination of dietary change, physical activity and behavioral modification.

Lifestyle Modification

Advantages of Weight Loss

  • Reduction in blood pressure, lipid levels (eg total cholesterol, triglycerides, and LDL) and all-cause mortality
    • Decrease in blood pressure (<130/80 mmHg), LDL <3.4 mmol/L, fasting blood glucose <5.5 mmol/L
  • Risks of developing diabetes mellitus and osteoarthritis are reduced

Dietary Therapy

  • Energy expenditure should be more than total energy intake
  • Consumption of low fat, low calorie diets are important for successful weight loss for 12 months
  • Eating breakfast is important to control weight and increase metabolism for the day
  • Calories
    • 500-1000 kcal/day reduction from usual intake to achieve weight loss of 1-2 lb/week
    • Intake of 1200-1500 kcal/day for most women, and 1500-1800 kcal/day for most men
    • Calorie reduction may also be simplified by using a 9-inch plate with half of the plate composed of vegetables and fruits and the other half divided between carbohydrates and protein 
  • Fats
    • Amount reduced will depend on each specific country’s national standard
    • Total fat should be ≤30% of total calories (trans fat <1%, saturated fat 7-10%, monosaturated fat up to 15% of total calories); with most fats coming from fish, nuts and vegetable oils
  • Carbohydrates
    • Should comprise 55% of total calories
    • Complex carbohydrate from fruits, vegetables and whole grains are preferred
  • Protein
    • Should be ≤15% of total calories
    • Derived from plant source or lean animal sources
  • Fiber
    • Should get ≥25-35 g/day
    • Delays gastric emptying causing a feeling of fullness and decreased appetite/hunger
    • Also helps decrease absorption of fat and cholesterol
    • May be obtained from oatmeal, whole wheat bread, rice, beans, citrus fruits, carrots, cauliflower, strawberries, peaches, and apple with skin
  • Vitamins and minerals
    • Calcium: 1000 mg/day depending on local guidelines (especially for women at risk of osteoporosis)
    • Vitamin D: 10-20 mcg/day

Modified Diets

  • Low-Calorie Diet (LCD)
    • Food-based approach intended to lower caloric intake by 500 kcal/day from maintenance requirement regardless of macronutrient composition
    • Contains approximately 40 g fat, 200 g carbohydrate, and 70 g protein
    • An average of 8-10% reduction in total body weight was noted over a 6-month period
  • Very Low-Calorie Diet (VLCD)
    • Caloric intake of 800 kcal/day regardless of macronutrient composition 
    • Uses calorie-controlled, vitamin/mineral fortified liquid meals utilized as the only nutrient source, substituting all meals
    • Used for max of 12 weeks; requires use of supplements and monitoring under experienced practitioners
    • Indicated in moderately to severely obese patients who are motivated but have failed with conservative methods, or in patients with BMI of 27-30 who have medical conditions that might respond to rapid weight loss 
    • Weight loss of approximately 20 kg is noted within the first 6 months; fast regain between 6-12 months
  • Best done by a certified nutritionist or dietitian 
    • Physicians should also consult with nutrition professionals when prescribing a particular weight loss diet that will address the patient’s needs 

Physical Activity

  • There is very strong evidence supporting the role of physical activity in the prevention and management of cardiovascular disease and diabetes mellitus
  • Studies have shown that losing weight is difficult with moderate-intensity physical activity only
  • Moderate-intensity exercises (eg swimming, table tennis, 3-4 mph brisk walking, 10 mph cycling) are recommended for 30-60 minutes, 5 days/week (>150 minutes a week)
    • 30 minutes/day for cadiovascular fitness
    • 60 minutes/day or >250 minutes/week to control body weight after weight loss
  • Resistance training using major muscle groups in single-set exercises may also be advised 2-3 times/week
  • Appetite is suppressed during and immediately after exercise, but increases after an hour
  • Activity should be tailored to patient’s age, ability, cardiovascular risk
  • Increase in daily activity should be encouraged (eg walking, climbing stairs)
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