An analytic review of current therapies for obesity.
Pessimism with therapy aimed at weight reduction was first voiced in a 1959 landmark paper by Stunkard and McLaren-Hume.  Using strict methodological criteria, they studied outpatient treatments available at that time. They found that 25% of the patients studied lost 9.1 kg (20 lb), and only 5% were able to lose 18.2 kg (40 lb). In 1977 Wing and Jeffery  reported only slight improvement in the effectiveness of treatment. Currently, health professionals professionals still have difficulty advising patients on the best method to lose weight.
In this paper the most popular, available weight-loss methods are analyzed and recommendations are offered for various categories of obese adult patients.
The first, and for many the only, intervention prescribed by primary care providers is a low-calorie diet, generally 800 to 1500 kcal/d.
The majority of studies concerned with dietary control of obesity have been performed on metabolic wards and on small numbers of subjects with short-term follow-up only. One study, however, revealed that on a 1200-kcal balanced diet, obese subjects lost 0.45 kg (1 lb) per day for the first 5 days and 0.3 kg (0.7 lb) per day for days 7 through 10.5 Because of high attrition rates and problems in monitoring and assessing compliance, no studies have been reported that investigated weight loss on a calorically restricted diet administered through a physician's office.
Many physicians prefer to have patients counseled by nutritionists when available. In 1959 Stunkard and McLaren-Hume  reported their experience at Cornell Medical Center following 100 patients referred to the nutrition clinic. Routine treatment in that setting was less successful than the clinical outpatient programs also reviewed in that paper. Only 12% were able to lose 9.1 kg (20 lb) and 1% lost 18.2 (40 lb). There was a 40% attrition rate, and 28% never returned to the primary provider or to a clinic. One year later, six of the 12 patients who had lost 9.1 kg (20 lb) maintained that loss, and after 2 years, only two had maintained it. There have been no more recent data to refute this dismal record.
Very Low Calorie Diets
In the late 1970s a number of authors reported remarkable weight reduction in morbidly obese patients using very low calorie diets. [6-9] Initial enthusiasm dampened when resultant widespread unsupervised use of these diets in the form of liquid protein led to a number of deaths. A very low calorie diet contains fewer than 800 kcal/d.  A popular form of the very low calorie diet is the protein-sparing modified fast. Its purpose is essentially starvation, while providing enough protein to maintain nitrogen balance and, it is hoped, lean body mass. Uncontrolled studies show weight loss at 1 to 2 kg per week (2.2 to 4.4 lb) for women and 1.5 to 2.5 kg per week (3.3 to 5.5 lb) for men.  Programs with a minimum duration of 12 weeks have a mean weight loss of 20 kg (44 lb).10 This amount of weight loss may be compared with the average loss for conventional diets plus behavior therapy of 5 to 7 kg in 12 weeks, with only 10% achieving a 20-kg loss. 
The attrition rate in very low calorie diet programs is 33% to 50%.  Maintenance of weight loss has not been studied thoroughly, but results are disappointing. The best results have shown that at 18 to 24 months of follow-up, one third of the original 20.8 kg (45.8 lb) lost had been gained back.  Many (22%) of the patients in this study, however, were lost to follow-up. Other studies have found 50% to 78% of the subjects returning to their original weight within 1 to 3 years. 10 Because of the high cost, most of the patients are of high socioeconomic status. The most common adverse side effects include orthostatic hypotension, constipation, hair loss, cold intolerance, and menstrual irregularities. Despite depression and other emotional responses that have been attributed to dieting,  psychiatric problems associated with these very low calorie diets have been extremely uncommon. [6,7,10,12]
Properly supervised, low-calorie diets appear safe when compared with liquid-protein diets. The deaths attributed to cardiac arrhythmias (quite likely, torsade de pointes) following the liquid-protein diets were probably due to preexisting illnesses, low-quality protein, and no potassium supplementation. Follow-up with short- and long-term electrocardiographic monitoring for those treated with very low calorie diets have shown no arrhythmias. The possibility exists that very low calorie diets may be even safer than diuretics in obese hypertensive patients; the results of the Multiple Risk Factor Intervention Trial suggested that in some hypertensive patients diuretic therapy may have contributed to increased cardiovascular mortality. 
BEHAVIOR MODIFICATION THERAPY
Over the last 20 years, behavior modification therapy has become the dominant therapeutic approach to weight control. Treatment assumes that obesity is the consequence of overeating, an abnormal behavior that can be unlearned. Stunkard and Berthold  have reported on the elements of a typical behavior-modification program: stimulus control, eating behavior (eg, putting fork down between mouthfuls, leaving some food on the plate, no reading or watching television while eating), reward, self-monitoring, nutrition education, physical activity, and cognitive restructuring. In most structured programs, participants meet weekly for about 1 hour in a group format. The length of the program is variable and can last from 6 weeks to 6 months, with an average of 10 to 12 weeks.
Of the hundreds of clinical behavioral therapy trials reported, many have lacked control groups, but results are remarkably consistent [15-18]
1. In the best programs, attrition rates are approximately 15%.
2. Weight loss is only moderately successful (average is 5 kg or 11 lb) and represents a fraction of the goal.
3. Further weight loss does not occur after active intervention ends.
4. Weight loss is maintained for 1 year, but, after that, slow weight gain is the rule.
5. Although significantly greater weight loss can be achieved over a longer period of therapy, rate of loss diminishes over time.
6. Results are extremely variable and cannot be predicted by demographics or patient characteristics.
7. There have been no negative side effects associated with behavioral therapy.
Behavior-modification therapy is often used as an adjunct to therapies such as exercise, low-calorie diets, and anorectic drugs. This approach has been used in a variety of settings, such as the workplace, and by nonprofit and commercial self-help groups. Behavior Modification in the Work Setting Virtually all weight control programs in the work setting have been behavior therapy programs. [19-22] Results, at best, have been similar to clinical behavior therapy programs, with the average participant losing about 0.5 kg (1 lb) per week. Many programs achieve only one-half that.  Maintenance of weight loss in worksite programs has also been similar to that of clinical programs; however, no experience has been reported with a follow-up of longer than 1 year. Attrition rates average about 50%, and Brownell et al" postulate that the reasons for this high rate might include (1) low cost to the participant, (2) too convenient, (3) social pressure from management to enroll, and (4) lower socioeconomic status of worksite participants.
BEHAVIORAL AND OTHER THERAPIES IN
SELF-HELP AND LAY GROUPS
Throughout the years, numerous for-profit and nonprofit self-help and lay groups for weight control have arisen in the community. Although as private organizations they have the advantage of being able to reach large numbers of people, little objective information is available. TOPS (Take Off Pounds Sensibly) is a nonprofit group designed after the principles of Alcoholics Anonymous. Group sessions consist of weighing in, public praise or censure for weight loss or gain, group discussion, and singing. From 1969 to 1970, Garb and Stunkard  studied 21 local chapters and found mean weight loss between 6.4 and 6.8 kg (14 to 15 lb). They also found very high attrition rates of 47% at 1 year and 70% at 2 years. Volkmar et al  studied commercial weight control programs. These too had high attrition rates, 50% at 6 weeks and 70% at 12 weeks. In the most effective commercial group studied, the average weight loss for participants was 7.1 kg (15.6 lb) in 12 weeks; however, no long-term follow-up was reported.  Ashwell and Garrow  in the United Kingdom found similar results in 1974 in three weight control organizations whose programs consisted basically of dietary advice. Attrition rates were 59% after 6 months, 77% after 1 year. Participants in Weight Watchers lost significantly more than those in the other two groups (11.8 kg vs 8.6 kg vs 7.3 kg).
In 1974, Levitz and Stunkard  showed that the addition of behavior therapy to some community-based TOPS chapters significantly decreased attrition rates to approximately 40% at 1 year. Initial weight loss was greater compared with controls, and at a 12-month follow-up, program enrollees had continued to lose, while those in control groups had gained over their pretreatment weights. After these results were known, many commercial groups were quick to add a behavioral modification component to their programs. TOPS, however, did not keep the behavioral modification component and reverted back to its old program.
There is substantial evidence that exercise is beneficial to those suffering from obesity, diabetes, and hypertension. Although it is clear that obese people are much less active, relatively little attention has been paid to methods that promote energy expenditure in the obese. The pessimistic attitude toward exercise derives from the finding that energy expenditure in even very vigorous training programs is quite low, compared with the amount of kilocalories contained in 1 kg of adipose tissue.  Exercise programs have high attrition rates (70% to 80%) in the first 1 to 2 years, in spite of participants viewing them as a positive experience. 21 These data come from studies of cardiac rehabilitation programs, not from studies of programs directed principally toward the obese. It appears difficult for these cardiac patients to incorporate exercise into their everyday lives. It is not clear whether that conclusion can be generalized to the obese population.
Exercise alone can cause weight loss in obese subjects. Weight loss obtained through exercise may be difficult to compare with weight loss obtained through other methods, however, because exercisers may preferentially lose adipose tissue and preserve, or even increase, lean body mass. [28,29] Nonexercising dieters lose both adipose tissue and lean body mass. In a study comparing a 700-kcal diet, nutrition and health education, behavior treatment, and exercise, successful weight loss was defined as 16 kg (35 lb).  The best predictor of success was exercise. Exercise added to behavior therapy can cause greater weight loss than either therapy alone. 
Walking is favored for obese, unconditioned patients. Few patients (and even providers) are aware of the commitment required to obtain results. While 22 dropped out of the study, Gwinup  Was able to follow 11 women who walked at least 30 minutes each day for 1 year without any dietary restrictions. Weight loss paralleled the amount of time spent exercising per day, with most occurring in those who exercised more than 3 hours per day. Average loss was 10 kg (22 lb), but those who discontinued exercise had rapid weight gain. Weight loss was always slow. Skinfold decrease was much greater than expected for the amount of weight loss, suggesting that weight loss involved fat and was accompanied by some increase in muscle mass.
Seventy-two mildly obese (average was 121 % ideal body weight) Boston police officers were treated with an 800-kcal diet. Some performed aerobic exercise and attained 70% to 85% maximal heart rate for 22 to 46 minutes three times a week, and some did not exercise.  At the end of 8 weeks, both groups had lost a clinically significant amount of weight, 11.8 kg (26 lb) in the exercise groups 9.2 kg (20.2 lb), but the composition of weight loss was different. Those who exercised did not lose any lean body mass (determined by total body potassium-40 measured in a body counter), while in the nonexercising group 36% of the weight loss was lean body mass.
According to these studies, it appears that the typical amount of weight loss attributable to aerobic exercise programs is 10 to 12 kg (22 to 26 lb). Long-term follow-up greater than 1 year has not been documented.
In 1972 the Federal Drug Administration (FDA)  published an analysis evaluating the effectiveness of anorectic drugs in over 200 double-blind studies and 10,000 subjects. It concluded that weight loss attributable to drugs was trivial (less than I kg per week) compared with the risks involved. In 1973 the FDA severely limited the use of amphetamines and other anorectics for treating obesity because of multiple side effects, the potential for addiction, and widespread abuse.
Phenylpropanolamine, an active ingredient in many diet pills sold over the counter, is a sympathomimetic also present in many nasal decongestants. Although one study (using placebo and controls) showed weight loss over a 4-week period with this drug, long-term effectiveness has never been studied.  Several reports tell of untoward side effects, including hypertensive crises and psychotic episodes, in those using these over-the-counter preparations. [35,36]
Benzocaine, usually incorporated into a candy, is a relatively safe topical anesthetic that purports to dull the taste buds and thus curb the appetite. One placebo-controlled study found short-term weight loss of 3.2 kg (7 lb), but another obtained mixed results. [31,38]
Since it does not affect the noradrenergic system, fenfluramine is an anorectic with a mechanism of action different from other drugs. Fenfluramine can cause weight JOSS.39 A recent trial, however, showed that although subjects using fenfluramine plus a diet lost more weight than subjects using diet alone at 3 months, this difference disappeared at 6 months.  Craighead et al  published a large-scale, controlled trial comparing fenfluramine with behavior therapy and concluded that therapy with fenfluramine produced more rapid regaining of weight and interfered with long-term benefits of behavior therapy. SURGERY
Payne, DeWind, and others [42,43] pioneered clinical trials using jejunoileal bypass to treat morbid obesity. Theirs and a number of other studies documented impressive weight loss, but, unfortunately, jejunoileal bypass has many postoperative complications, including liver fibrosis in 5% of patients. In 1% of all patients, this fibrosis leads to fatal cirrhosis. [4-6]
Because of the morbidity associated with jejunoileal bypass, various forms of gastric-restriction procedures have been developed. Gastric bypass was first performed by Mason and Ito in 1967.  Operative mortality rates, similar to those for jejunoileal bypass, average 4%, ranging from 0% to 6%.  In contrast, however, serious postoperative complications such as reflux gastritis and marginal ulcerations are relatively rare. Nausea and vomiting are minor complications reported by a majority of patients in the immediate postoperative period. Weight loss, averaging 2 to 2.5 kg per month (4.4 to 5.5 lb),49 usually ceases after 20 to 26 months. Average total weight loss is between 40 and 70 kg (88 to 154 lb).
Studies of bilateral truncal vagotomy in a small number of patients have shown average weight loss of 20 to 30 kg (44 to 66 lb) in a 4-to 24-month follow-up. [50-51] Side effects include foul-smelling eructations, diarrhea, and fatigue. The hypothesis is that weight reduction may (1) be due to alterations in vagally mediated central and peripheral mechanisms for appetite regulation, and (2) reflect delayed gastric emptying.
Jaw wiring, known also as maxillomandibular fixation or dental splinting, is another means of weight reduction in the morbidly obese. The Adelaide Obesity Group reported a median weight loss of about 40% of excess weight over 6 months.  Kark  reported on 14 morbidly obese patients followed over a period of 2 years. Patients were encouraged to limit their diet to 800 kcal of fluids and liquidized soft foods. The mean duration of wiring was 8.6 months, with average weight loss of 29.8 kg (65.5 lb). Only one of the patients had maintained the weight loss at the end of the 2-year study, and there was a 50% attrition rate. Some centers have achieved more satisfactory results by first using jaw wiring, with attendant rapid early weight loss, and then performing gastric bypass surgery.  The purpose is to make the abdominal surgery less hazardous technically.
This experimental technique has been likened to an artificial bezoar, a large intragastric mass of foreign material. It can be tolerated for long periods with few symptoms except for weight loss. The balloon is a soft, plastic cylinder inserted into the stomach using endoscopy in an outpatient procedure that takes about 30 minutes. The FDA recommends that the device be removed after 4 months.
Garren  reported on 100 morbidly obese patients who received this type of treatment along with behavior modification therapy, nutritional counseling, and individualized low-calorie diets of about 1000 kcal/d. Balloons were replaced every 4 months; the longest treatment period was 1 year. Mean cumulative weight loss was 18.2 kg (40 lb) over a 6-month period, and 34.8 (76.5 lb) over a 10-month period. Complications included balloon deflation in 9% of cases, with consequent increase in hunger. The device then either passed without pain in the stool or was removed endoscopically. One balloon deflated and caused partial gastric-outlet obstruction, and another required surgical removal after lodging in a site of prior surgery that contained an adhesion. The majority of patients developed nausea, cramping, and vomiting during the first 3 days, but symptoms responded to antiemetic and antispasmodic medications. Gastric ulcerations developed in four patients.
Long-term maintenance of weight loss has yet to be demonstrated. [54,55] Recent reports of complications, including esophageal rupture, small-bowel obstruction, and difficulty deploying the device from the introducer, may dampen initial enthusiasm for this treatment. [16-19] Several controlled trials are ongoing at present, and their results will be important in determining the future of this device.
RECOMMENDATIONS This paper does not address the problem of childhood obesity. Nor does it address the controversy over whether being moderately overweight contributes to increased mortality; this issue has been discussed elsewhere.  One should note also that few studies have investigated potential ill effects of obesity in specific groups such as minorities, women, and the elderly, and that conclusions based on other populations may not be applicable.  It is clear, however, that obesity worsens many common diseases, such as diabetes and hypertension, and weight loss can be one of the most important treatments for these conditions. [61-64] Morbid obesity, defined as 45.5 kg or 100 lb overweight or 200% of ideal body weight, particularly in the young adult, doubles the risk of mortality above that of the general population.  Given this information, morbidity caused by invasive methods of weight control becomes more acceptable as physicians and patients balance individual risks.
Table 1 [omitted]is a summary of the current therapeutic approaches to obesity and their outcomes, with respect to expected maximum weight loss, rates of attrition, long-term efficacy, and morbidity. Given the varied alternatives for therapy, the benefits and, for some, the risks, how should the office-based physician manage adult patients with obesity? Training of physicians in behavior modification techniques might prove beneficial. These techniques, however, have most often been applied in group settings, and the average intervention has been very time-intensive (1 hour per week for 10 to 12 weeks). Most physicians have neither the time nor training to provide such services in the office. As there are no formal studies on the impact of diet counseling in the physician's office, and given the poor record of diet counseling by more formally trained nutritionists, there is little to suggest that physicians can expect more than occasional success. Courses that combine behavior modification and nutrition information are increasingly available in the community, sponsored by work sites, self-help organizations, or private consultants. Physicians should become aware of the resources and their quality in their community. Beyond diet and behavior modification, the high-risk obese patient requires specialty consultation focusing increasingly on surgical interventions.
Recommendations for patients at various levels of weight and risk are summarized in Table 2. These recommendations are based on the amount of desired weight loss and applying the least morbid intervention that can be reasonably expected to give that amount of weight loss. Expected outcomes for these interventions are based on the analysis in this review. Clearly, validation of these recommendations by direct, prospective comparison would be optimal. In particular, the paucity of information on the long-term efficacy of weight loss interventions should make this aspect a research priority. Considering the sobering results of interventions, inquiry must focus on prevention. Such risk factors as stress, depression, poverty, poor basic understanding of nutrition, and a strong family history of obesity should be warning signs for the patient and physician. Education and simple warnings of risk before obesity occurs may prove to be the best intervention, considering the understanding physicians have of this puzzling and tenacious illness at this time.
This paper was supported in part by grants from the Health Resources and Services Administration, Department of Health and Human Services, and the Harvard-Ryoichi Sasakawa International Fellowship Program in Primary Care.
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TABLE 2. RECOMMENDATIONS FOR VARIOUS CATEGORIES Desired Weight Loss intervention Less than 9.1 kg Diet counseling plus behavior therapy (20 lb) community-run or worksite programs Exercise program Aerobic exercise for 30 min at least 3 times per wk Walking for 30 min at least 7 times per wk 9.1 to 45.5 kg Medically supervised very low calorie diet (20 to 1 00 lb) Behavior therapy, diet counseling, and exercise More than 45.5 kg Surgical intervention; gastric restriction (100 lb) Prior to surgery, consider very low calorie diet, gastric balloon, behavior therapy, diet counseling, and exercise
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|Author:||Holmes, Michelle D.; Zysow, Bernice; Delbanco, Thomas L.|
|Publication:||Journal of Family Practice|
|Date:||May 1, 1989|
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