Obesity : evaluation and treatment essentials

217 Pages·2010·2.51 MB·English

by  G Michael Steelman, Eric C Westman

Obesity
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Evaluation and Treatment Essentials l
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About the book n

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Addressing a growing epidemic in today’s world, Obesity: Evaluation and Treatment Essentials presents practical W
treatment protocols for obesity, including exercise, pharmacology, behavior modification, and dietary factors, from
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the point of view of the practicing physician.
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Encompassing a multidisciplinary audience of clinicians and researchers, this comprehensive resource is an invaluable, t
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user-friendly tool for bariatric physicians and surgeons, endocrinologists, diabetologists, nutritionists, dieticians, and
all those who treat obesity. Written by prominent members of the American Society of Bariatric Physicians, this text: a Evaluation and
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• Showcases successful treatment methods by including key points of various clinicians in each chapter.
• Includes an up-to-date chapter on the pharmacology of bariatric medicine that identifies the three classes of
obesity drugs: those that increase energy expenditure, those that decrease energy intake, and those that inhibit
Treatment Essentials
the digestion and absorption of food.
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• Addresses various dietary intervention approaches such as low calorie balanced diets, low carbohydrate diets, and
very low carbohydrate diets. b
• Explores the comorbidities of obesity, such as hypertension, cardiovascular disease, and Type II diabetes. e
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About the editors i
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G. MIchAEl STEElMAn M.D., F.A.S.B.P., is board certified in Bariatric Medicine, Family Practice, Anti-Aging Medicine y
and neuro-linguistic Programming. Dr. Steelman is past President of The American Society of Bariatric Physicians. he

served as an advisor to the American Obesity Association, Medical Director of Eating Disorders at Mercy health System
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of Oklahoma, and an advisor to former Surgeon General c. Everett Koop. Dr. Steelman has worked in private practice for
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over 30 years and runs the renowned Steelman clinic in Oklahoma city. he is editor of The American Journal of Bariatric a
Medicine and was named Bariatrician of the Year by the American Society of Bariatric Physicians in 1993 and 2006. l
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ErIc c. WESTMAn M.D., M.h.S., is board certified in Internal Medicine. he is an Associate Professor of Medicine and
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Director of the lifestyle Medicine clinic at Duke University health System, Durham, north carolina. Dr. Westman io
received his M.D. from the University of Wisconsin, completed his Internal Medicine residency at the University of n
Kentucky, and received a Masters degree in biostatistics during a General Medicine Fellowship at Duke University a
Medical center. he is a Fellow of The Obesity Society and the Society of General Internal Medicine. Dr. Westman is n
also Vice-President of the American Society of Bariatric Physicians and in 2009 he received the Steelman-Seim Educator d
Award for advancing the cause of healthcare through education and teaching. T
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Telephone house, 69-77 Paul Street, london Ec2A 4lQ, UK a
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52 Vanderbilt Avenue, new York, nY 10017, USA
Eric C. Westman
www.informahealthcare.com
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Obesity
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fm IHBK070-Steelman June9,2010 6:32 Trim:7in×10in
Obesity
Evaluation and Treatment
Essentials
Edited by
G. Michael Steelman, MD, FASBP
American Society of Bariatric Physicians
The Steelman Clinic
Oklahoma City, Oklahoma, U.S.A
Eric C. Westman, MD, MHS
Lifestyle Medicine Clinic
Duke University Medical Center
Durham, North Carolina, U.S.A
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Firstpublishedin2010byInformaHealthcare,TelephoneHouse,69-77PaulStreet,LondonEC2A4LQ,UK.
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Foreword
Obesity: The word itself doesn’t conjure up many positive emotions from people at- large or
busydoctors.Perhaps,beingfatwasagoodthingintheyearAD1000whenourancestorswere
running around, and there were no supermarkets on the corners. Who survived when there
wasafamineandpassedtheirgenepoolsdowntous?Generally,itwasn’ttheskinnyones.
Significantcorpulencewasoutofvoguebythe1860s,atthetimeofourCivilWar.William
(cid:2) (cid:2)(cid:2)
Banting,a5 5 ,202lb,undertakerinmerryoldEnglandtriednearlyeverythingtoloseweight
withoutsuccess.AhearingproblemledhimtoseeDr.WilliamHarvey,anear,nose,andthroat
doctor of some renown. Dr. Harvey thought Banting’s hearing problem might be related to
hisobesityandsuggestedareducedcarbohydratediet(withstillafewspiritsallowed).Low-
carbohydratedietswereusedtotreatdiabetesinthepre-insulinera.Followingthiseatingplan,
Banting lost weight nicely and kept it off. He was so happy that he wrote and distributed a
pamphlet about his success. This stirred up considerable discussion at the time, and, by the
early1900s,somepeople,insteadofsaying,“itstimetodiet”weresaying,“itstimetoBant.”
No,Iwasn’ttherethen,butIdorememberthe“GreatDepression”(whatwassogreatabout
thedepressionofthe1930s?).Anyway,inthe1950sand1970scurbingtheintakeofcarbswas
moreinvoguethankeepingthedietaryfatdown.Yudkin,inEngland,wasalow-carbohydrate
advocateandwaspublishedseveraltimesinthisregardinthe1970s.
Thenthe“experts”camealong,tellingustokeepthefatdownandloaduponnonrefined
carbohydrates, etc. Low and behold, we’ve continued getting fatter. They’ve been fattening
Iowahogswithanonrefinedcarbohydrate,namelycorn,fordecades.ThelastIchecked,they
weren’tusingthefibrousveggies,likecabbageorzucchini.
So,it’snicetohaveabooklikeObesity:EvaluationandTreatmentEssentialsthatcovers
itall.It’swrittenprimarilybypracticingBariatricians,whomaketheirlivingtreatingpatients
withobesityproblems.Therearealsochapterswrittenbyacademicianswhohavebeendoing
research involving human obesity for quite some time, plus chapters by experts on exercise,
behaviormodification,andnutrition.Allinall,youhaveanoutstandinggroupofexpertswho
bringitalltogether.Thisbookisanexcellentreadforthoseofuswhohavebeentreatingthe
obeseforyearsandneedtobebroughtuptodate.It’sespeciallybeneficialfordoctorswhoare
gettinginto,orthinkingaboutgettinginto,thefieldofBariatricMedicine.Inessence,thisbook
isamusthaveforpracticingBariatricians.
Let me give you a short history regarding the appetite suppressants. Starting in 1969 I
leadtheAmericanSocietyofBariatricPhysicians(ASBP)from35obesity-treating,duespaying
physicianmemberstoapproximately450by1974.Currently,theASBPhasover1000members.
Inthelate1960sandearly1970s,themothersofAmericawerecryingfortheFedstotakethe
amphetamineappetitesuppressantsoffthemarket,sotheirkidswouldn’tbeabusingthem.I
flewbacktoWashington,D.C.,andspenttimeattheFDApresentingtheASBP’spositionthat
atleastsomeoftheappetitesuppressantsshouldremainavailableforthetreatmentofobesity.
Barrett Scoville, MD, a career FDA bureaucrat involved with the issue, said he had
reviewedthestudiessubmittedinthe1960stogetapprovalforthenon-amphetamineappetite
suppressantsandthat,overthe12-weekstudyperiods,thosegettingtheappetitesuppressants
lost about a pound a week and those taking the placebos lost about one-half pound a week.
Tohimthatwasn’tasignificantdifference.Therefore,heopinedthatallappetitesuppressants
shouldbetakenoffthemarket.ImadetheASBP’spositionclearthatwestronglyopposedsuch
action.CharlesEdwards,MD,wasanotherphysicianworkingattheFDAatthetime.Hehada
littlecoolerhead.Aftermuchdiscussion,theupshotwasthattheamphetaminesmovedupto
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vi FOREWORD
scheduleII(noappetitesuppressantusage)andtheotherthree,phentermine,diethypropion,
andphendimetrazine,wentintoScheduleIIIorIV,withthe“fewweek”limitationbeingput
inthepackageinsertmaterial.So,wedohavethemandmostofusBariatriciansusethem“off
label.”Ido,andI’vehadpatientsonthemmoreorlesscontinuouslyfor30years.Isawapatient
afewweeksagowhoisstillfightingtheweightbattleatage69,andshewas27yearsoldwhen
I first saw her. Certainly, this doesn’t make me feel any younger. Obviously, she wouldn’t be
comingbacktoseemeifshewasn’tneedingandgettingongoinghelp.
So, let’s get back to the FDA and the BNDD (now DEA). I asked Barrett at the time to
define what a “few weeks” meant. He said they weren’t going to do that. I had my appetite
suppressants,so,“begone.”Overthenextseveralyears,“fewweeks”cametobeinterpreted
as12weeks,whichwasthelengthoftimemoststudiesweredonetogetthesedrugsapproved
bytheFDAinthe1960s.
I’ve had patients come in and say “I didn’t think the medication was helping but, boy,
whenIdidn’thaveit....”Iftheappetitesuppressantscontinuedworkingliketheydothefirst
fewweeks,wewouldn’thavemuchofanobesityproblem—theydon’t,butevenwithlong-term
usage,theydohelptokeepthehungerlevelsdownenoughsothatpatientscanmakeintelligent
foodchoices.Iftheydo,theywon’tbesohungry.
I’vealwayssaid“Youwon’tkeepverymanypatients,ifthey’reveryhungry,verylong.”
So,Iwelcomethewaythisbookcoverstheappetitesuppressantsplusmuch,muchmore.Thank
you,MichaelSteelman,MD,FASBP,andEricWestman,MD,MHS,astheeditorsforObesity:
Evaluation and Treatment Essentials, and thanks to all chapter contributors for doing a fine
job covering the other aspects of the obese state, its treatment, and what may be in store for
Bariatriciansandourpatientsinthenottoodistantfuture.
Inshort,IhighlyrecommendObesity:EvaluationandTreatmentEssentials.Onwinding
downmyhistorylesson,I’mremindedofthestoryofaseven-year-oldboyinchurchwhokept
lookingaroundandgenerallyappearedbored.Onthewayoutthepastor,whohadnotedthe
boy’sbehavior,shookhishandandaskediftherewasanythinghecouldhelphimwith.The
seven-year-oldasked“Whatarethoseplaquesonthewallwiththenameanddatesonthem?”
To which the pastor replied, “Son, those are our members who have died in the service.” To
this,theyoungladasked,“Inthe8o’clockserviceorthe10o’clockservice?”
Thus,Iwinddownmycommentarybeforethereadersstartasking,“... the8o’clockor
the10o’clock?”
W.L.Asher
Littleton,Colorado,U.S.A.
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Preface
Itisclearthatobesityisoneofournation’sbiggesthealthcarechallenges.Itisassociatedwith
ourmostcommoncausesofmortalityandmorbidityaswellaswithproducingconsiderable
psychosocialdiscomfort. Theincidenceof this killerdiseasehas beensteadilyincreasing and
hasreachedepidemicproportions.
Most physicians receive little or no training in nutritional matters or the treatment of
obesity.Perhapsbecausethetreatmentofobesityislessglamorousandmorefrustratingthanthe
treatmentofotherconditions,toomanyphysiciansareunableorunwillingtodelivereffective
medical assistance to overweight patients struggling to manage their weight. Too often, this
void is filled by commercial interests more focused on “the bottom line” rather than on the
healthoftheconsumer.
The treatment of obesity has been hindered by myths, misconceptions, and prejudices
aboutitscausesandconsequences.Theobeseindividualisnotsimplyalazy,metabolicallynor-
maladultwithtoomuchadiposetissue;rather,heorsheisametabolicallycomplexindividual
whomayresponddifferentlytonutritionalintakeandexercise/activity.
The causes of obesity are complex and multifactorial. Its treatment, therefore, must be
multimodalandtailoredtomeettheindividualneedsoftheparticularpatient.Thisbookwill
discusstheessential,clinicalguidelines,andstandardsofeachtreatmentoptionfromdietary
interventionstobariatricsurgery,aswellasthebariatrician’sroleinthistreatmentoption.
Dietaryinterventionisthemainstayofbariatrictreatment.Inordertoindividualizetreat-
ment,thephysicianneedstobefamiliarwithvariousapproaches,includinglowcaloriediets,
low-carbohydrate diets, and very low-carbohydrate diets (VLCD). It is our hope that nutri-
tionists and dieticians will benefit from the detail and level of discussion of these dietary
interventionsinadditiontothebariatricphysician.
Exerciseisanimportantpartofweightlosseffortsandisprobablyessentialforlong-term
weight maintenance. It provides numerous benefits in addition to its effect on weight. While
patientsarewillingtofollowalmostanydietplan,itisoftendifficulttogetthemtoinitiateand
sustainameaningfulexerciseregimen.
Weight loss and maintenance require that individuals make changes in the way they
interact with their environment. In this effort, they battle with a culture that, on one hand,
valuesbeingfitandtrimand,ontheother,promotesobesogenicfoodpatternsandsedentary
lifestyles.Tosucceed,theoverweightindividualmustbearmedwitheffectivestrategiestodeal
withinternalandexternalforcesthatfavortheoverweightstate.
Various pharmaceutical agents have been used to help facilitate weight loss. Anorectic
agentshavebeeninuseforoverfourdecadesandhavebeenshowntobebothsafeandeffective.
Neweragentsthatinhibittheabsorptionoffatorcarbohydratearealsoavailable.Variousother
pharmaceuticalsandsomenaturalsubstancesmayalsoplayaroleinhelpingwiththeprocess
ofweightmanagement.Ontheotherhand,therearemanycommonmedicationsthatpromote
weightgain,andreplacingthesewithonesthataresimilarlyeffectivebutlesslikelytoimpact
weightnegativelycanoftenbringrewardingresults.
Wemustalsoconsider,whentreatingthebariatricpatient,thatchildrenrepresentaspe-
cialpopulationwithspecialneeds.Theincreasingincidenceofobesity(andattendanttypeII
diabetes)inthispopulationisalarming.Clearly,somethingmustbedonetostemthistideor,
ashasbeensuggested,today’sgenerationofchildrenwillbethefirstgenerationofAmericans
withalifeexpectancylessthanthatoftheirparents.ThechapteronChildhoodObesityclearly
identifiesthespecialneedsofchildrenandoutlinesapproachesformanagingtheobesechild.
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viii PREFACE
Forsomeindividuals,obesityanditscomorbiditiesadvancetosuchadegreethattheirlife
isatconsiderablerisk.Forthem,bariatricsurgerymaybewarranted.Itisessentialthattheybe
properlyevaluatedbeforesurgery,skillfullytreatedduringsurgery,andfollowedappropriately
afterwards.Thebariatricphysicianplaysanimportantroleintreatingthepatientperioperatively
ifbariatricsurgeryisadeterminedmethodoftreatmentforaparticularpatient.
Thoseofuswhohavedevelopedaspecialinterestandspecializeinthefieldofbariatric
medicinefindgreatsatisfactionintheworkwedoandtheroleweplayinhelpingourpatients
live healthier, happier, and longer lives. We are excited about the potential for better under-
standingofthiscomplexandfascinatingdiseaseandforthedevelopmentofbetterweaponsto
useinitstreatment.
Toourcolleaguesengagedinacademicandclinicalresearch,weofferoursincereappre-
ciationforyoureffortsandeagerlyawaitthefruitsofyourlabor.
Toourcolleaguesengagedinclinicalpracticewhoareawakeningtothisfieldandwant
toimprovetheirskillsandexpertiseinthemedicalmanagementofobesepatients,weextend
ourheartfeltencouragementandsupport.
G.MichaelSteelman,MD,FASBP
EricC.Westman,MD,MHS
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Contents
Foreword W.L.Asher....v
Preface....vii
Contributors....xi
1. Obesity:thescopeofagrowingproblem 1
HaroldC.Seim
2. Etiologiesofobesity 5
LarryA.Richardson
3. Healthhazardsofobesity 25
G.MichaelSteelman
4. Evaluationoftheobesepatient 35
JamesT.Cooper
5. Dietarytreatmentoftheobeseindividual 43
MaryC.Vernon,EricC.Westman,andJamesA.Wortman
6. Theroleofphysicalactivityinthetreatmentoftheobeseindividual 57
DeborahBadeHorn
7. Behavioralmodification 72
ErinChamberlin-Snyder
8. Pharmacotherapy 81
EdJ.Hendricks
9. Maintenanceofweightloss 100
ScottRigden
10. Surgicaltreatmentoftheobeseindividual 108
JohnB.Cleek
11. Medicaltreatmentofpediatricobesity 120
MaryC.VernonandEricC.Westman
12. Residentiallifestylemodificationprogramsforthetreatmentofobesity 127
HowardJ.EisensonandEricC.Westman
13. Currentresearchandfuturehope 139
FrankL.GreenwayandStevenR.Smith