How to Lose Weight

How many more calories a day does the average American eat today compared to someone in

1970• A. 200

• B. 300

• C. 400

• D. 500

• E. 523

Answer

• E. 523

What has changed to increase the calories?

Answer

• Larger portions

• Increased processed fats and sugars

Can Physicians make interventions that are meaningful

for weight loss, control of BP, BS and Cholesterol in routine

clinical practice?

Reducing Blood Pressure Levels Effectively in Practice• Two interventions each helped to modify this cardiovascular risk factor successfully, but staffing

such programs would be costly.

• Practice guidelines for the prevention of cardiovascular disease identify clear targets for risk-factor modification but often say little about the difficult objective of actually achieving them. Now, we have data on two strategies specifically designed to help patients with uncontrolled CVD risk factors reach their prevention goals.

• In one study from a California county health system, researchers enrolled 419 low-income patients (mean age, 55; 66% women; 85% nonwhite) who had at least moderately uncontrolled, modifiable CVD risk factors. Participants (19% with established CVD, 63% with diabetes) were randomized to receive usual care or one-on-one nurse- and dietician-led case management that emphasized behavior modification and medical management. At 15 months, the mean Framingham risk score (FRS) had declined significantly more in the case-management group (by 0.92 points to 7.80) than in the usual-care group (by 0.19 points to 8.93). FRS changes were consistent across sex and racial subgroups. Most of the advantage of case management was attributable to significant declines in systolic and diastolic blood pressures. Using prior data on the association between risk-factor modification and outcomes, the researchers estimated that the case-management program would prevent 1 adverse cardiovascular event in every 200 patients.

Reducing Blood Pressure Levels Effectively in Practice• In the other study, six family medicine clinics in Iowa (serving 402 patients with poorly

controlled hypertension) were randomized to (1) an intervention in which pharmacists monitored patients and offered treating physicians guideline-based medication-intensification recommendations for lowering blood pressure or (2) no intervention. Because clinics — not patients — were randomized, baseline characteristics differed significantly in some respects; for example, patients at the control clinics had lower initial blood pressures and were more likely than intervention patients to have no insurance and to have diabetes. The researchers adjusted for such differences and found that, compared with patients at the control clinics, those at the intervention clinics had significantly lower systolic blood pressure at 6 months (about 12 mm Hg lower, on average, despite the baseline disadvantage) and were significantly more likely to achieve blood pressure control (odds ratios: 3.2 in the overall cohort and 4.7 among diabetic patients).

• Comment: Each of these studies identified an intervention that reduced blood pressure effectively among patients with uncontrolled risk factors in clinical practice. However, both programs require substantial staffing, which is costly. Without meaningful financial incentives for achieving risk-factor modification in community practice, implementing such interventions in the broader population would likely be difficult, despite their effectiveness.

• — Frederick A. Masoudi, MD, MSPH

Conducting brief interventions• workbook or information sheet • advantages of workbook—gives patient something

to take home, think about, and refer to• Clinician sits beside patient while discussing

contents of workbook, or information sheet.• It conveys sense of teamwork; because patient does

not have to look at clinician, he or she may experience less fear of stigma and find communication easier

Identify goals• what does patient want to achieve over next 3 mo to 1 yr?• include goals about physical health, activities and

hobbies, and relationships• So you would like to be able to walk one mile with your

gramd kids. Lets start with the chair exercise program, stand and walk in place 15 seconds 100 times a day, and work up to that mile

• You would like to lose 20 pounds so lets start by eating breakfast and reducing some carbohydrates and reducing high calorie foods from your diet

Screening: summary of patient’s health habits

• Ask questions about exercise, smoking, nutrition, alcohol use, and (particularly in older adults) medications

• How much do you exercise?

• What do you eat?

• Do you eat breakfast?

• Do you drink fruit juices, soda, alcohol?

• Ask the patient which health habits he or she wants help with?

Discussion• Address patient’s health concerns, but allow redirection of

conversation to weight loss• Ask patient for his or her definition of a good weight• Educate the patient about accepted definitions by doing

BMI, body fat, waist circumference, and fat calipers• Inquire about what patient likes about eating (eg, taste,

greater comfort in social situations, reduced stress and/or loneliness);

• Gently inform patient of negative consequences obesity• Discuss reasons for cutting down on consumption

Weight loss agreement• The clinician makes suggestion of goal for

reducing weight

• You may need to negotiate with patient about frequency, timing, and/or quantity of weight loss and appointments

• The patient may not agree, but clinician records recommendations and both parties sign agreement

Understanding HungerTo understand how emotional or mindless eating work, it's important to know about the two types of

hunger:

• real hunger

– grows gradually

– you'll eat anything

– can wait

– you stop when you're full

– you feel good after eating

– you gain energy

• emotional hunger

– hits suddenly

– you crave a specific food (usually high in fat)

– needs to be satisfied instantly

– you can't stop, period

– you feel guilty after eating

– you gain weight

Get the Patient into a different Mindset

Traditional diets are a short-term fix to a long-term problem.

But the key to losing weight and keeping it off has to be learned over time.

Over time, healthy eating will become habit.

Over time, you'll become more active, and more content.

Over time, your life can get more satisfying—and stay that way.

How to start

• Plan

• Today decide what you will eat tomorrow.

• Write it down and keep it in your pocket.

• Here are three winning tips to get you started.

How to start• Don't let yourself go hungry• Eat breakfast in the morning. You need high fiber and protein

to fill you up and make you less hungry. • Reduce carbohydrates except for a small serving of dark

chocolate in the morning, to give you some immediate energy. Dark Chocolate has allot of antioxidants that are good for you

• Try eating 3 main meals and healthy snacks in between. This keeps you feeling satisfied while avoiding cravings from your external hunger.

• Take time to plan and schedule tomorrow's healthy meals—and stick to your plan.

How to get started• Take 15 minute breaks

• Satiety—that's the feeling of being full. Unfortunately there's about a 15-minute lag between when you're stomach gets this message and when you're brain gets it. Eating more slowly can give your stomach the quarter of an hour it needs to relay your fullness status to your brain. Taking 15 can help you avoid overeating. Find a partner and make lunch and snacks at work a social occasion. A little chat can make that 15 minutes feel like nothing.

How to get started• Arm yourself with healthy snacks

Healthy snacks are a great way to stay satisfied between meals and help make sure that you're eating at least every 4 hours. Low-fat foods, like fresh fruit, fat-free pudding cups, and low-fat crackers, will keep you from getting too hungry and grabbing the first thing you see. If you're running around or working, keep some unsalted pretzels in your bag. Have some hummus in your work fridge and bring in some carrot and celery sticks. Give yourself options when you're working or on the move.

We won't sugar coat it. It's hard to eat healthy when you eat out. Restaurant meals usually contain more salt and fat and sugar than the dishes you whip up at home. But with a little insight, you can hit your favorite restaurants and still eat for optimum health. Look for the low-fat proteins. Favor low-fat food prep techniques like grilling. Watch out for those hidden calories-they're lurking in mayo and in cream-based sauces. And remember, restaurant portions are generally way more food than you need.Go for chicken and seafood-protein options with less saturated fat than red meatAsk for meat and fish to be grilled, definitely not friedMake sure there are veggies on your plateGo for tomato-based sauces as opposed to cream-basedAlways order dressings on the side-so you stay in control, and see if there are lower-fat alternatives availableTry mustard instead of mayo, or choose a low-fat mayoForget that guilt-trip your parents gave you about always cleaning your plate. Leaving food on your plate is a victory, proof of your new-found power over food

Restaurant dinning tactics• Stick to the appetizer and salad sections of the menu. Make veggie-

based choices for your appetizers. Make the main course a Cobb or grilled chicken salads. Avoid the fried chicken-strip salad and the Caesar salad.

• Dip into salad dressing. Go for a fat-free or low-fat dressing. Dip your fork into the dressing, and then the salad-you'll still get the flavor you want, but not more than you need.

• You're special-so don't be shy about special orders. Most restaurants are happy to modify meals to make customers happy. Don't be afraid to ask the server how a dish is prepared. If the dish is high in fat, ask if they can cook the steak without butter, or grill or broil the fish instead of frying. Even if you have to pay a little extra, the benefits to your health are worth the small difference in price.

Restaurant dinning tactics

• Always be the first to order. Listening to the choices that friends or family make at restaurants may influence your decision, even if you have the best intentions. Eliminate the temptation by being the first to order. When you're done eating, ask for your plate to be removed, so you don't pick.

• Order à la carte This is especially true for fast-food restaurants. For instance, the regular price for a sandwich might be $3, but for $4 you also get chips and a soda. You might think you saved money, but you actually spent more, got food you didn't want, and extra calories you don't need.

• Split meals with a friend. Many restaurant portions are enough for two people to split-and making a meal a social occasion has the added benefit of forcing you to eat more slowly, so you sense satiety before you've overeaten. If you're on your own, get a doggie bag and place half your meal in it when it is served. It will keep that portion out of sight and make a great lunch the next day.

Restaurant dinning tactics• Be vigilant-hidden calories can be anywhere. Many dishes contain more calories than you realize because of breading,

sauces, or frying. This is how hidden fat sneaks into your meal. If you aren't certain what a meal comes with or how it is prepared, ask your server. If you see any of the following words describing a menu item, your stealth calorie detector should start tingling.Au gratin

• Parmesan• Cheese sauce• Scalloped• Rich• Creamy, cream sauce• Buttered, buttery• Pastry• Breaded• Fried• Seasoned• Southern-style• Limit your alcohol. Alcohol is loaded with empty calories and it's all too easy to consume too much alcohol without thinking

about it, especially when you're with friends, having a Friday lunch, or blowing off steam after work. Stick to white wines and the lighter versions of your favorite lager beer. Sparkling water with lime or lemon is a refreshing, healthful alternative.

• Ban the breadbasket. Whether it's dinner rolls, breadsticks, or tortilla chips, ask the server not to bring it, or push it out of immediate reach. The starch basket tends to contain a lot of refined white-flour products-lots of calories, minimal nutritional value.

Restaurant dinning tactics• Skip dessert or have fruit-based desserts. Resist dessert if you're full and not

internally hungry. Remind yourself you can have something later, when your body-not your psyche-is hungry again. Otherwise, consider good-tasting but low-calorie choices like sorbet, low-fat or fat-free frozen yogurt, angel food cake, or fresh fruit.

• Ask for backup. Let your buddies in on your program. True friends will embrace an opportunity to help you. Ask them to keep the starch basket on their side of the table, and not egg you on to that rich dessert or second glass of Pinot grigio.

• Monitor your emotions. Slipping up is human, but you are less likely to do it if you ask yourself "What do I want from this meal?" before you enter the restaurant. If you do overeat, don't kick yourself. You're human and you've embraced a long term-based positive program for change. And, if you do decide to eat more, don't consider it a catastrophe later. Review your past Steps (accomplishments), chat with peers, or write in your journal to get back on track. One meal will not make or break your program for healthier change.

Ten Myths About Obesity

Tobacco-related mortality

• data from Centers for Disease Control and Prevention (CDC) showed that obesity-related mortality growing at rate that would soon overtake tobacco- related mortality

• methodology of data analysis criticized• findings refuted• tobacco remains leading cause of preventable

death in United States (obesity second)

Childhood obesity: only partially true that epidemic slowing down

• overweight in children defined as body mass index (BMI) >85th percentile of average weight for age group,

• based on cohort from 1960s and 1970s (obese >95th percentile,

• severely obese >97th percentile)

• downward trend

• in childhood obesity among whites, but increase seen in black and Latino communities

Effect of weight on mortality• BMI—underweight <18.5;• normal 18.5 to 25• overweight 25 to 30• obesity class I 30 to 35• obesity class II 35 to 40• obesity class III (extreme obesity) >40• National Health and Nutrition Examination Survey (NHANES) data—3 studies over 20 yr; slightly higher

mortality of underweight category largely due to smoking (most smokers thinner)• obesity (all classes) associated with excess mortality, but risk not dramatically higher (relative risk [RR]

1.8)• overweight (BMI 25-30) not associated with excess mortality• in blacks BMIs of 27 to 30 associated with normal outcomes• while in Asians, BMIs as low as 23 may be associated with excess mortality• clinician’s role—determine whether patient has type of overweight associated with adverse outcomes• look for metabolic syndrome (measure waist circumference, blood pressure, lipids)• take family history• current data—risk attributable to obesity decreasing over time, possibly because of better management of

related conditions

Overweight and Mortality in an Older Population

• Above-normal BMI was somewhat protective in women.• Are overweight elders at elevated risk for death, compared with those whose weight is normal? To find

out, Israeli researchers identified about 2400 Jerusalem elders (age range, 70–85 at baseline) and followed them for 3 to 18 years. Normal, overweight, and obese were defined as body-mass index (BMI) of 18 to 24.9 kg/m2, 25 to 29.9, and 30, respectively.

• In analyses that were adjusted for potentially confounding factors that could predispose to death, women who were overweight or obese had significantly lower mortality than women with normal BMIs. In men, mortality was similar in all three BMI categories. In additional analyses, the researchers omitted deaths that occurred during the first several years of follow-up, to account for "reverse causality" (which would occur if lower-weight people had diseases at baseline that would cause death within a relatively short time); this maneuver did not affect the results.

• Comment: In this study of an older population, being overweight or mildly obese was not associated with shorter survival. Indeed, having above-normal BMI was somewhat protective in women. These results should not be used to justify weight gain as people age; rather, the implication is that overweight people in their 70s and 80s should not necessarily be pushed to lose weight if they are otherwise active and well. These results do not apply to severe obesity, which was not well-represented in this cohort.

• — Allan S. Brett, MD• Published in Journal Watch General Medicine January 19, 2010

Case: woman 40 yr of age with BMI 33; which abnormality best predicts her 10-yr mortality? waist

circumference (36 in); fasting blood glucose (110 mg/dL)

systolic blood pressure (BP; 140 mm Hg)

triglycerides (185 mg/dL); exercise test (stopped after stage 2)

• g

answer

• —exercise test best predictor

Fit and fat• study confirmed earlier findings that sedentary

lifestyle doubles risk for premature death over 14 yr

• Fitness more important than weight for measurement of health

• study showed fat but fit subjects lived longer than thin but unfit subjects

• findings not replicated in other studies, but fitness always shown to mitigate weight-related morbidities

• urge patients to become as fit as possible, regardless of their weight

Exercise• not sufficient for weight loss• improves variety of metabolic factors (small dose-response

effect) with or without weight loss• recommend focusing initially on exercise duration and

frequency rather than on intensity• That is why doing a body fat % is important. You can tell

patient even if you do not lose weight if on your next visit your body fat is less you have more muscle you are doing a good job and you are healthier.

• By doing multiple measures you have multiple ways to measure fitness.

Diet• necessary for weight loss• transtheoretical model’s stages of change applicable to prescribing diet and

weight loss strategies• intervention should focus on stage of patient’s change• diet type less important than adherence to Diet• similar effectiveness seen with various popular diets, including meal

replacement (very low calorie), Atkins (low carbohydrate), Ornish (vegetarian); Zone (balanced macronutrient)

• mean intake 1400 calories/day on all diets• Lowcarbohydrate approach possibly slightly better• Universal use of low-fat diet no longer evidence-based• patient should have adequate social support and frequent visits with peer

support, dietician, or physician

Rapid weight loss• very low calorie diet (VLCD)—800 calories/day

• preplanned meals with adequate vitamins, minerals, and proteins

• meta-analysis showed patients on VLCD lose weight twice as quickly as those on traditional low-calorie diet (LCD; 1200 to 1400 calories/day) in short term;

• LCD in clinical setting results in loss of 5% to 10% (average 7.5%) of patient’s original weight

• VLCD 15%

• weight loss in short term; VLCD indicated in patients who want to lose high volume of weight without surgery

• VLCD indicated In patients with need for rapid weight loss (eg, orthopedist recommends knee surgery, but requires that patient first lose 50 lb or patient too heavy for bariatric surgery table)

Average Weight Loss

• Low Calorie Diet 5 to 10% of body weight

• 7.5 % is average

• Very Low Calorie Diet 15% of body weight

• Gastric bypass 30% of body weight

A very low-calorie diet (VLCD)

• A very low-calorie diet (VLCD) is a doctor-supervised diet that typically uses commercially prepared formulas to promote rapid weight loss in patients who are obese. These formulas, usually liquid shakes or bars, replace all food intake for several weeks or months. VLCD formulas need to contain appropriate levels of vitamins and micronutrients to ensure that patients meet their nutritional requirements. Some physicians also prescribe VLCDs made up almost entirely of lean protein foods, such as fish and chicken. People on a VLCD consume about 800 calories per day or less.

• VLCD formulas are not the same as the meal replacements you can find at grocery stores or pharmacies, which are meant to substitute for one or two meals a day. Over-the-counter meal replacements such as bars, entrees, or shakes, should account for only part of one’s daily calories.

• When used under proper medical supervision, VLCDs may produce significant short-term weight loss in patients who are moderately to extremely obese. VLCDs should be part of comprehensive weight-loss treatment programs that include behavioral therapy, nutrition counseling, physical activity, and/or drug treatment.

VLCDs• VLCDs are designed to produce rapid weight loss at the start of a weight-loss program in

patients with a body mass index (BMI) greater than 30 and significant comorbidities. BMI correlates significantly with total body fat content. It is calculated by dividing a person’s weight in pounds by height in inches squared and multiplied by 703.

• Use of VLCDs in patients with a BMI of 27 to 30 should be reserved for those who have medical conditions due to overweight, such as high blood pressure. In fact, all candidates for VLCDs undergo a thorough examination by their health care provider to make sure the diet will not worsen preexisting medical conditions. Lastly, these diets are not appropriate for children or adolescents, except in specialized treatment programs.

• Very little information exists regarding the use of VLCDs in older adults. Because adults over age 50 already experience depletion of lean body mass, use of a VLCD may not be warranted. Also, people over 50 may not tolerate the side effects associated with VLCDs because of preexisting medical conditions or the need for other medicines. Doctors must evaluate on a case-by-case basis the potential risks and benefits of rapid weight loss in older adults, as well as in patients who have significant medical problems or are on medications. Furthermore, doctors must monitor all VLCD patients regularly—ideally every 2 weeks in the initial period of rapid weight loss—to be sure patients are not experiencing serious side effects.

VLCD • A VLCD may allow a patient who is moderately to extremely

obese to lose about 3 to 5 pounds per week, for an average total weight loss of 44 pounds over 12 weeks. Such a weight loss can rapidly improve obesity-related medical conditions, including diabetes, high blood pressure, and high cholesterol.

• The rapid weight loss experienced by most people on a VLCD can be very motivating. Patients who participate in a VLCD program that includes lifestyle treatment typically lose about 15 to 25 percent of their initial weight during the first 3 to 6 months. They may maintain a 5-percent weight loss after 4 years if they adopt a healthy eating plan and physical activity habits.

side effects• Many patients on a VLCD for 4 to 16 weeks report minor side

effects such as fatigue, constipation, nausea, or diarrhea. These conditions usually improve within a few weeks and rarely prevent patients from completing the program. The most common serious side effect is gallstone formation. Gallstones, which often develop in people who are obese, especially women, are even more common during rapid weight loss. Research indicates that rapid weight loss may increase cholesterol levels in the gallbladder and decrease its ability to contract and expel bile. Some medicines can prevent gallstone formation during rapid weight loss. Your health care provider can determine if these medicines are appropriate for you

Maintaining Weight Loss

• Studies show that the long-term results of VLCDs vary widely, but weight regain is common. Combining a VLCD with behavior therapy, physical activity, and active follow-up treatment may help increase weight loss and prevent weight regain.

• In addition, VLCDs may be no more effective than less severe dietary restrictions in the long run. Studies have shown that following a diet of approximately 800 to 1,000 calories produces weight loss similar to that seen with VLCDs. This is probably due to participants’ better compliance with a less restrictive diet.

• For most people who are obese, their condition is long-term and requires a lifetime of attention even after formal weight-loss treatment ends. Therefore, health care providers should encourage patients who are obese to commit to permanent changes of healthier eating, regular physical activity, and an improved outlook about food

Study showing Medifast's effectiveness in patients with type 2 diabetespublished in 'The Diabetes Educator'

• OWINGS MILLS, Md., February 11, 2008- /PRNewswire-FirstCall/ -- Medifast, Inc. (NYSE: MED) today announced that a study conducted by researchers at the Johns Hopkins University Bloomberg School of Public Health, showing the Medifast Program outperforms the American Diabetes Association (ADA) recommended diet for patients with type 2 diabetes, has been published in the January/February issue of 'The Diabetes Educator'. The peer-reviewed journal is the official journal of the American Association of Diabetes Educators.

• The examiner of the study from Johns Hopkins University submitted the study and informed Medifast that the study has been published in the most appropriate venue to help train diabetes educators about the effectiveness of Medifast Meal Replacements in the treatment of type 2 diabetes. The study was finalized for publication within the last 12 months after being presented to physicians and scholars attending the American Diabetes Association Convention in 2005.

• "This study is one of many that validate the efficacy of Medifast Meal Replacements in the clinical setting," said Brad MacDonald, Chairman of the Board, Medifast, Inc. "Medifast continues to invest in the research and development of its products and programs to ensure that our claims to consumers are the most documented and credible in the industry."

• In the study, the Medifast Program outperformed the ADA recommended diet in weight loss, adherence and biochemical outcomes. These findings suggest a re-evaluation of the ADA recommendation, which currently does not promote portion-controlled meal replacement programs in weight loss and weight maintenance for individuals with diabetes, is warranted.

• The results of the study also suggest that meal replacements may achieve the same outcomes in diabetics as bariatric surgery (though over the longer term), while mitigating the increased risk of morbidity and mortality associated with these more dangerous treatment approaches.

• "A close friend of mine had some serious complications because of type 2 diabetes and it scared me to death," said Medifast client Steven Eldridge, of Raytown, MO. "I was suffering from the disease myself and decided to consult my doctor. He said the best thing I could do is to lose the weight, and that's when I found Medifast. I lost 114 pounds in 5 months on the Medifast Program and am totally off my diabetes medication for the first time in 6 years, which is an absolute miracle, and I have Medifast to thank!"

• The study compared Medifast's effectiveness for weight control in people with type 2 diabetes to the standard ADA recommended dietary guidelines. The study enlisted 112 overweight or obese people with type 2 diabetes using two weight loss approaches of equal caloric prescription - the Medifast Program and a traditional reduced-calorie diet based on the ADA recommended dietary guidelines.

• According to the results, participants randomized to receive Medifast lost twice as much weight and were twice as compliant with the diet as participants following the standard ADA diet. Approximately 40 percent of the Medifast participants lost greater than 5 percent of their initial weight, compared with 12 percent of those on the standard ADA diet. Additionally, 24 percent of the Medifast users decreased or eliminated their diabetes medication, compared to 0 percent on the standard ADA diet.

• Medifast will continually participate in studies in the future, which will add even more credibility to the Medifast Brand and Programs. For more than 25 years Medifast has been prescribed by practitioners as a safe and effective program that yields significant results and has been proven to provide significant weight loss of 2-5 pounds per week.

• "Over 20,000 physicians have recommended Medifast since 1980 and millions of consumers have realized the health and wellness benefit of our program," says Michael S. McDevitt, Chief Executive Officer, Medifast, Inc. "The publication of this study adds to Medifast's already stellar reputation in the medical community."

The Medifast PlanFor Women

• The Medifast 5 & 1 Plan helps women lose weight quickly, leading to tremendous improvements in overall health. Medifast is much more than the traditional, fad diets that may have failed your patients in the past. Medifast helps your patients lose the weight - and teaches them how to keep it off! The Medifast program is convenient, portion-controlled, and simple to follow. Your patients will see and feel results in the first week!

• Most women start by ordering the Medifast for Women 4-Week Package. With this package your patients receive the most popular Medifast Meals - and save over $30!

• Medifast also has a unique line of shakes, specially formulated to meet the specific health needs of women. Medifast Plus for Women's Health Shakes contain black cohosh, Echinacea, and chaste tree berry - these ingredients help reduce symptoms of menopause, such as hot flashes or night sweats.

The Medifast PlanFor Men

• The Medifast 5 & 1 Plan helps your patients lose weight quickly, improve their overall health, and take charge of their eating for life. Remember, Medifast is a lifestyle change, not just a short-term weight loss solution. We won't abandon your patients the way fad diets have in the past. Our Transition, Maintenance and Exercise Plans pick up where the 5 & 1 Plan ends - and teach your patients how to sustain their weight loss results long term!

• The quick weight loss results your patients experience will inspire and motivate them to embrace Medifast as an essential part of their new, healthy lifestyle.

• Most men start by ordering the Medifast for Men 4-Week Package and save over $30 on the most popular Medifast Meals.

The Medifast PlanFor Seniors

• Medifast for Seniors is a Medifast Program specifically designed for adults over age 70. The Medifast for Seniors Program is different from the Medifast 5 & 1 Plan.

• Maintaining a healthy weight is beneficial for people of all ages. As one gets older, achieving and maintaining a healthy weight becomes crucial to their overall state of health. The Medifast for Seniors Program is convenient and easy to follow, emphasizing portion-controlled eating at regular intervals throughout the day.

• Seniors have 2 options for Medifast Meal Plans. As their physician, you can help decide which option is right for your patient.

• OPTION 1: The Medifast 4 & 2 & 1 Plan

• 4 Medifast Meals + 2 Lean & Green Meals + 1 Healthy Snack

• 1000-2000 calories daily

• 100+ grams of carbohydrates daily

• Weight loss will be slow and steady

• Patient will not be in fat burning state with this plan

• OPTION 2: The Medifast 5 & 2 & 2 Plan

• 5 Medifast Meals + 2 Lean & Green Meals + 2 Healthy Snacks

• 1,300-1,500 calories daily

• 130+ grams carbohydrates daily

• Weight loss may be slower paced, but patient will still lose weight at a healthy rate

• Patient will not be in fat-burning state with this plan

OPTIFAST Program• At the heart of the OPTIFAST Program is a portion-controlled, calorically precise,

nutritionally complete diet that takes the guesswork out of eating. The benefits of OPTIFAST shakes, soups and bars include:

• High-quality, complete nutritionPre-portioned and calorie-controlled servingsStimuli narrowingQuick and simple preparationFreedom from having to make food choices

• During the Active Weight Loss phase, patients consume only the OPTIFAST meal replacements. Hunger typically goes away after the first week. Many patients report increased energy, attributed to more stable blood sugar levels, balanced diet, decreased weight, and increased activity level.

• The active weight loss phase is followed by a 4-6 week transition period during which participants gradually add self-prepared foods back to their diets. Participants move to a long-term weight management program rich in fruits and vegetables, grains and low-fat proteins. During the program they will have learned techniques to include small amounts of their favorite foods into their new healthy lifestyle. The Food & Nutrition section ofResources contains links to many helpful nutrition and meal planning resources.

OPTIFAST provider• Becoming an OPTIFAST provider means access to a vast array of expertise and services to member

clinics, including:• Skilled Resources

– The OPTIFAST Team includes former and current OPTIFAST Program Directors, physicians, registered dietitians, registered nurses, nutrition scientists, exercise physiologists and clinical researchers.

• Professional Resources– Key program staff learn how to manage a comprehensive weight management program from

business, medical, nutritional and educational perspectives. Components include:– • The OPTIFAST Program Training Startup Manual– • Online Training Modules– • 2-day live training in Minneapolis, MN – • Ongoing mentoring by your OPTIFAST account manager– • Regional OPTIFAST Conferences

• Clinical Support Services– In addition to customized assistance from their account manager, OPTIFAST clinics receive access

to a wealth of research data, marketing materials and support, and operations support.

Optifast and Bariatric Surgery• Nutritional therapy prior to bariatric procedures can provide significant

benefits to surgeons and patients alike:

• Presurgery

• Improved transition to postoperative diet and behaviorReduced fatty liver and decrease in liver volumeDecreased visceral adipose tissue

• Postsurgery

• Reduced risk of liver trauma and blood lossReduced laparoscopic procedure timeIncreased weight loss first year postoperatively

• Some OPTIFAST clinics and bariatric surgery centers offer presurgical support programs to help prepare patients for surgery. Many OPTIFAST clinics also welcome bariatric patients into their overall long-term management programs and continue to provide OPTIFAST product to those patients who were started on OPTIFAST prior to surgery.

After weight loss• myth that after successful weight loss, patients can return to “sensible”

(1800 calories/day) diet

• Patient must maintain 1400 calorie/day diet for rest of life or weight will be regained

• supported by data from National Weight Control Registry

• maintaining weight loss requires high levels of physical activity (1 hr of moderate-intensity exercise daily)

• Exercise 6 days a week

• low-fat or low-carbohydrate diet

• regular selfmonitoring of weight

• “grazing” rather than binging

• Avoid fast foods

• weekend diet and exercise regimen same as weekday regimen

NWCR Facts• You may find it interesting to know about the people who have enrolled in the registry thus far.•  • 80% of persons in the registry are women and 20% are men.• The "average" woman is 45 years of age and currently weighs 145 lbs, while the "average" man is 49 years of age and currently

weighs 190 lbs.• Registry members have lost an average of 66 lbs and kept it off for 5.5 years.• These averages, however, hide a lot of diversity:

– Weight losses have ranged from 30 to 300 lbs.– Duration of successful weight loss has ranged from 1 year to 66 years!– Some have lost the weight rapidly, while others have lost weight very slowly--over as many as 14 years.

•  We have also started to learn about how the weight loss was accomplished: 45% of registry participants lost the weight on their own and the other 55% lost weight with the help of some type of program.

• 98% of Registry participants report that they modified their food intake in some way to lose weight.• 94% increased their physical activity, with the most frequently reported form of activity being walking.• There is variety in how NWCR members keep the weight off. Most report continuing to maintain a low calorie, low fat diet and

doing high levels of activity.•  

– 78% eat breakfast every day.– 75% weigh themselves at least once a week.– 62% watch less than 10 hours of TV per week.– 90% exercise, on average, about 1 hour per day.

Persons successful at long-term weight loss and maintenance continue to

consume a low-energy, low-fat diet.• Shick SM, Wing RR, Klem ML, McGuire MT, Hill JO, Seagle H.• Department of Epidemiology, University of Pittsburgh School of Medicine, PA 15213, USA.• Comment in:• J Am Diet Assoc. 1998 Nov;98(11):1273.• OBJECTIVES: To describe the dietary intakes of persons who successfully maintained weight loss and to determine if differences

exist between those who lost weight on their own vs those who received assistance with weight loss (eg, participated in a commercial or self-help program or were seen individually by a dietitian). Intakes of selected nutrients were also compared with data from the third National Health and Nutrition Examination Survey (NHANES III) and the 1989 Recommended Dietary Allowances (RDAs). SUBJECTS: Subjects were 355 women and 83 men, aged 18 years or older, primarily white, who had maintained a weight loss of at least 13.6 kg for at least 1 year, and were the initial enrollees in the ongoing National Weight Control Registry. On average, the participants had lost 30 kg and maintained the weight loss for 5.1 years. METHODS: A cross-sectional study in which subjects in the registry completed demographic and weight history questionnaires as well as the Health Habits and History Questionnaire developed by Block et al. Subjects' dietary intake data were compared with that of similarly aged men and women in the NHANES III cohort and to the RDAs. Adequacy of the diet was assessed by comparing the intake of selected nutrients (iron; calcium; and vitamins C, A, and E) in subjects who lost weight on their own or with assistance. RESULTS: Successful maintainers of weight loss reported continued consumption of a low-energy and low-fat diet. Women in the registry reported eating an average of 1,306 kcal/day (24.3% of energy from fat); men reported consuming 1,685 kcal (23.5% of energy from fat). Subjects in the registry reported consuming less energy and a lower percentage of energy from fat than NHANES III subjects did. Subjects who lost weight on their own did not differ from those who lost weight with assistance in regards to energy intake, percent of energy from fat, or intake of selected nutrients (iron; calcium; and vitamins C, A, and E). In addition, subjects who lost weight on their own and those who lost weight with assistance met the RDAs for calcium and vitamins C, A, and E for persons aged 25 years or older. APPLICATIONS: Because continued consumption of a low-fat, low-energy diet may be necessary for long-term weight control, persons who have successfully lost weight should be encouraged to maintain such a diet.

Behavioral strategies of individuals who have maintained long-term weight losses.

• McGuire MT, Wing RR, Klem ML, Hill JO.• University of Pittsburgh Medical Center, PA 15213, USA. zie4@cdc.gov• OBJECTIVE: The purpose of the present study was to compare the behaviors of individuals who have

achieved long-term weight loss maintenance with those of regainers and weight-stable controls. RESEARCH METHODS AND PROCEDURES: Subjects for the present study were participants in a random-digit dial telephone survey that used a representative sample of the U.S. adult population. Eating, exercise, self-weighing, and dietary restraint characteristics were compared among weight-loss maintainers: individuals who had intentionally lost > or =10% of their weight and maintained it for > or = 1 year (n = 69), weight-loss regainers: individuals who intentionally lost > or = 10% of their weight but had not maintained it (n = 56), and weight-stable controls: individuals who had never lost > or = 10% of their maximum weight and had maintained their current weight (+/-10 pounds) within the past 5 years (n = 113). RESULTS: Weight-loss maintainers had lost an average of 37 pounds and maintained it for over 7 years. These individuals reported that they currently used more behavioral strategies to control dietary fat intake, have higher levels of physical activity (especially strenuous activity), and greater frequency of self-weighing than either the weight-loss regainers or weight-stable controls. Maintainers and regainers did not differ in reported levels of dietary restraint, but both had higher levels of restraint than the weight-stable controls. DISCUSSION: These results suggest that weight-loss maintainers use more behavioral strategies to control their weight than either regainers or weight-stable controls. It would thus appear that long-term weight maintenance requires ongoing adherence to a low-fat diet and an exercise regimen in addition to continued attention to body weight.

What predicts weight regain in a group of successful weight losers? .• McGuire MT, Wing RR, Klem ML, Lang W, Hill JO.• Department of Psychiatry, University of Pittsburgh Medical School, USA. zie4@cdc.gov• Erratum in:• J Consult Clin Psychol 1999 Jun;67(3):282.• This study identified predictors of weight gain versus continued maintenance among

individuals already successful at long-term weight loss. Weight, behavior, and psychological information was collected on entry into the study and 1 year later. Thirty-five percent gained weight over the year of follow-up, and 59% maintained their weight losses. Risk factors for weight regain included more recent weight losses (less than 2 years vs. 2 years or more), larger weight losses (greater than 30% of maximum weight vs. less than 30%), and higher levels of depression, dietary disinhibition, and binge eating levels at entry into the registry. Over the year of follow-up, gainers reported greater decreases in energy expenditure and greater increases in percentage of calories from fat. Gainers also reported greater decreases in restraint and increases in hunger, dietary disinhibition, and binge eating. This study suggests that several years of successful weight maintenance increase the probability of future weight maintenance and that weight regain is due at least in part to failure to maintain behavior changes.

The prevalence of weight loss maintenance among American adults.

• McGuire MT, Wing RR, Hill JO.• University of Pittsburgh Medical Center, PA, USA. mcguire@epi.umn.edu• BACKGROUND: Previous studies suggest that few individuals achieve long-term weight loss maintenance.

Because most of these studies were based on clinical samples and focused on only one episode of weight loss, these results may not reflect the actual prevalence of weight loss maintenance in the general population. DESIGN: A random digit dial telephone survey was conducted to determine the point prevalence of weight loss maintenance in a nationally representative sample of adults in the United States. Weight loss maintainers were defined as individuals who, at the time of the survey, had maintained a weight loss of > or =10% from their maximum weight for at least 1 y. The prevalence of weight loss maintenance was first determined for the total group (n = 500), and then for the subgroup of individuals who were overweight (body mass index BMI > or =27 kg/m2 at their maximum (n = 228). RESULTS: Weight loss was quite common in this sample: 54% of the total sample and 62% of those who were ever overweight reported that they had lost > or =10% of their maximum weight at least once in their lifetime, with approximately one-half to two-thirds of these cases being intentional weight loss. Among those who had achieved an intentional weight loss of > or =10%, 47-49% had maintained this weight loss for at least 1 y at the time of the survey; 25-27% had maintained it for 5 y or more. Fourteen percent of all subjects surveyed and 21% of those with a history of obesity were currently 10% below their highest weight, had reduced intentionally, and had maintained this 10% weight loss for at least 1 y. CONCLUSIONS: A large proportion of the American population has lost > or =10% of their maximum weight and has maintained this weight loss for at least 1 y. These findings are in sharp contrast to the belief that few people succeed in long-term weight loss maintenance.

Three-year weight change in successful weight losers who lost weight on a low-

carbohydrate diet.

• Obesity (Silver Spring). 2007 Oct;15(10):2470-7.

• Phelan S, Wyatt H, Nassery S, Dibello J, Fava JL, Hill JO, Wing RR.

• Department of Psychiatry and Behavioral Medicine, Brown Medical School, 196 Richmond Street, Providence, RI 02903, USA. sphelan@lifespan.org

• OBJECTIVE: The purpose of this study was to evaluate long-term weight loss and eating and exercise behaviors of successful weight losers who lost weight using a low-carbohydrate diet. RESEARCH METHODS AND PROCEDURES: This study examined 3-year changes in weight, diet, and physical activity in 891 subjects (96 low-carbohydrate dieters and 795 others) who enrolled in the National Weight Control Registry between 1998 and 2001 and reported >or=30-lb weight loss and >or=1 year weight loss maintenance. RESULTS: Only 10.8% of participants reported losing weight after a low-carbohydrate diet. At entry into the study, low-carbohydrate diet users reported consuming more kcal/d (mean +/- SD, 1,895 +/- 452 vs. 1,398 +/- 574); fewer calories in weekly physical activity (1,595 +/- 2,499 vs. 2,542 +/- 2,301); more calories from fat (64.0 +/- 7.9% vs. 30.9 +/- 13.1%), saturated fat (23.8 +/- 4.1 vs. 10.5 +/- 5.2), monounsaturated fat (24.4 +/- 3.7 vs. 11.0 +/- 5.1), and polyunsaturated fat (8.6 +/- 2.7 vs. 5.5 +/- 2.9); and less dietary restraint (10.8 +/- 2.9 vs. 14.9 +/- 3.9) compared with other Registry members. These differences persisted over time. No differences in 3-year weight regain were observed between low-carbohydrate dieters and other Registry members in intent-to-treat analyses (7.0 +/- 7.1 vs. 5.7 +/- 8.7 kg). DISCUSSION: It is possible to achieve and maintain long-term weight loss using a low-carbohydrate diet. The long-term health effects of weight loss associated with a high-fat diet and low activity level merits further investigation.

Holiday weight management by successful weight losers and normal weight

individuals.• J Consult Clin Psychol. 2008 Jun;76(3):442-8.• Phelan S, Wing RR, Raynor HA, Dibello J, Nedeau K, Peng W.• Department of Psychiatry and Human Behavior, Brown Medical School, Providence, RI 02903,

USA. sphelan@lifespan.org• This study compared weight control strategies during the winter holidays among successful

weight losers (SWL) in the National Weight Control Registry and normal weight individuals (NW) with no history of obesity. SWL (n = 178) had lost a mean of 34.9 kg and had kept > or = 13.6 kg off for a mean of 5.9 years. NW (n = 101) had a body mass index of 18.5-24.9 kg/m(2). More SWL than NW reported plans to be extremely strict in maintaining their usual dietary routine (27.3% vs. 0%) and exercise routine (59.1% vs. 14.3%) over the holidays. Main effects for group indicated that SWL maintained greater exercise, greater attention to weight and eating, greater stimulus control, and greater dietary restraint, both before and during the holidays. A Group x Time interaction indicated that, over the holidays, attention to weight and eating declined significantly more in SW than in NW. More SWL (38.9%) than NW (16.7%) gained > or = 1 kg over the holidays, and this effect persisted 1 month later (28.3% and 10.7%, respectively). SWL worked harder than NW did to manage their weight, but they appeared more vulnerable to weight gain during the holidays. (c) 2008 APA, all rights reserved

Weight-loss maintenance in successful weight losers: surgical vs non-surgical methods.

• Int J Obes (Lond). 2009 Jan;33(1):173-80. Epub 2008 Dec 2.• Bond DS, Phelan S, Leahey TM, Hill JO, Wing RR.• Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University/The

Miriam Hospital, Providence, RI, USA. dbond@lifespan.org• OBJECTIVE: As large weight losses are rarely achieved through any method except bariatric surgery, there have

been no studies comparing individuals who initially lost large amounts of weight through bariatric surgery or non-surgical means. The National Weight Control Registry (NWCR) provides a resource for making such unique comparisons. This study compared the amount of weight regain, behaviors and psychological characteristics in NWCR participants who were equally successful in losing and maintaining large amounts of weight through either bariatric surgery or non-surgical methods. DESIGN: Surgical participants (n=105) were matched with two non-surgical participants (n=210) on gender, entry weight, maximum weight loss and weight-maintenance duration, and compared prospectively over 1 year. RESULTS: Participants in the surgical and non-surgical groups reported having lost approximately 56 kg and keeping > or =13.6 kg off for 5.5+/-7.1 years. Both groups gained small but significant amounts of weight from registry entry to 1 year (P=0.034), but did not significantly differ in magnitude of weight regain (1.8+/-7.5 and 1.7+/-7.0 kg for surgical and non-surgical groups, respectively; P=0.369). Surgical participants reported less physical activity, more fast food and fat consumption, less dietary restraint, and higher depression and stress at entry and 1 year. Higher levels of disinhibition at entry and increased disinhibition over 1 year were related to weight regain in both groups. CONCLUSIONS: Despite marked behavioral differences between the groups, significant differences in weight regain were not observed. The findings suggest that weight-loss maintenance comparable with that after bariatric surgery can be accomplished through non-surgical methods with more intensive behavioral efforts. Increased susceptibility to cues that trigger overeating may increase risk of weight regain regardless of initial weight-loss method.

Consistent self-monitoring of weight: a key component of successful weight loss

maintenance.• Obesity (Silver Spring). 2007 Dec;15(12):3091-6.

• Butryn ML, Phelan S, Hill JO, Wing RR.

• Department of Psychology, Drexel University, 245 N. 15th Street, MS 626, Philadelphia, PA 19102, USA. mlb34@drexel.edu

• OBJECTIVE: The objectives were to investigate the characteristics associated with frequent self-weighing and the relationship between self-weighing and weight loss maintenance. RESEARCH METHODS AND PROCEDURES: Participants (n = 3003) were members of the National Weight Control Registry (NWCR) who had lost >or=30 lbs, kept it off for >or=1 year, and had been administered the self-weighing frequency assessment used for this study at baseline (i.e., entry to the NWCR). Of these, 82% also completed the one-year follow-up assessment. RESULTS: At baseline, 36.2% of participants reported weighing themselves at least once per day, and more frequent weighing was associated with lower BMI and higher scores on disinhibition and cognitive restraint, although both scores remained within normal ranges. Weight gain at 1-year follow-up was significantly greater for participants whose self-weighing frequency decreased between baseline and one year (4.0 +/- 6.3 kg) compared with those whose frequency increased (1.1 +/- 6.5 kg) or remained the same (1.8 +/- 5.3 kg). Participants who decreased their frequency of self-weighing were more likely to report increases in their percentage of caloric intake from fat and in disinhibition, and decreases in cognitive restraint. However, change in self-weighing frequency was independently associated with weight change. DISCUSSION: Consistent self-weighing may help individuals maintain their successful weight loss by allowing them to catch weight gains before they escalate and make behavior changes to prevent additional weight gain. While change in self-weighing frequency is a marker for changes in other parameters of weight control, decreasing self-weighing frequency is also independently associated with greater weight gain.

Medications• medicines really are not effective• phentermine—approved for 6 wk of use• weight usually returns upon termination of use• sibutramine – approved for 1 yr use ineffective• orlistat—prescription-strength approved for 2-yr use• topiramate—not approved for weight loss• exenatide—not approved for weight loss• drug vs placebo studies• average loss 5% of original weight; study results unreliable because subjects placed on

diet and exercise programs and behavioral therapy before start of medication trial• no data suggest >1-yr use of weight-loss medications reduces obesity-related morbidity

and mortality• drugs ineffective because multiple biologic systems (eg, central nervous system,

endocrine system) affect appetite, and when one suppressed, others remain active or compensate

Surgery• gastric bypass twice as effective as best

dietary intervention

• risk for death within 30-day post-operative period 0.5% to 2.0%

• factors affecting outcome include surgeon’s skill and patients’ preexisting comorbidities

Background for obesity surgery• obesity surgery differs from that of 7 to 10 yr ago

• >50% of Americans overweight or obese

• 1 in 25 Americans qualify for weight-loss surgery

• 75% of obese children become morbidly obese adults

• 1 in 3 children born after 2000 will develop type 2 diabetes

• each year 112,000 people die prematurely of obesity-related conditions

• (more than deaths from breast cancer, prostate cancer, and colorectal cancer combined)

• society incorrectly views obesity as result of acquired self-destructive behavior, rather than as disease

• obese individuals have lower rates of drug, tobacco, and alcohol use than national averages

• problem—food highly efficient vehicle for disease

• Most smokers do not get lung cancer and few chronic alcohol abusers get cirrhosis, but everyone who consumes more calories than they burn will gain excess weight

Background for obesity surgery• Candidates for weight-loss surgery

• National Institutes of Health (NIH) criteria recommend weight-loss surgery for patients with BMI over 40, or BMI over 35 plus hypertension, heart disease, sleep apnea, or diabetes

• nonsurgical weight-loss treatments have about a 95% long-term failure rate

• bariatric surgery only scientifically proven method for long-term weight loss; improves or cures diabetes, hypertension, sleep apnea, and other weight-related morbidities

Laparoscopic surgery• now standard bariatric procedure• compared to open procedures, results in reduced incidence of wound

infections, hernias, deep venous thrombosis, pulmonary embolism, and postoperative pneumnia as well as less pain and faster recovery

• only 1% to 2% of patients undergoing laparoscopy develop wound infection, hernia, or both (compared to 1 in 6 patients undergoing open procedures)

• recent improvements—standardized procedures• collaboration among surgeons nationally• improved patient selection• procedure should be done in patients <400 lb, preferably <300 lb as it

is safer and more effective

Goals of surgery• gastric banding—restriction of caloric

intake by restricting volume required for feeling of satiation

• patients eat 3 4-oz meals daily

• patients taught how to construct a low-calorie meal

• gastric bypass—restriction plus malabsorption

People loss weight in Gastric Bypass surgery by three

basic mechanisms, What are they?

Answer

• 1. Hormonal

• 2. Malabsorption

• 3. Dumping syndrome.

• What exactly is the mechanism for each method?

Answer• 1. Hormonal is the result of reduced Ghrelin in the

stomach. It is a hormone made by the stomach that makes you feel hungry

• 2. Malabsorption because of bypassing part of the small intestine

• 3. Dumping syndrome is an autonomic response to eating high osmolarity foods that as they pass from the reduced stomach directly into the jejunem cause sweating, distension and tachycardia. You get a bad feeling and the result is an Antibuse effect used to limit drinking Alcohol

NEJM Volume 346:1623-1630May 23, 2002Number 21NextPlasma Ghrelin Levels after Diet-Induced Weight Loss or Gastric Bypass Surgery

David E. Cummings, M.D., David S. Weigle, M.D., R. Scott Frayo, B.S., Patricia A. Breen, B.S.N., Marina K. Ma, E. Patchen Dellinger, M.D., and Jonathan Q. Purnell, M.D.

• Our finding of markedly reduced ghrelin levels after gastric bypass suggests that suppression of ghrelin can now be studied as a potential mechanism by which this procedure causes weight loss. This hypothesis offers a plausible explanation for theparadoxical reduction of hunger between meals that occurs after  gastric bypass, as well as for the observation that the procedure is more effective than gastroplasty in facilitating long-term weight loss.12,13,14,35,36,37,38,39,40 These operations produce equivalent gastric restriction,35,41 but only gastric bypass isolates ghrelin cells from contact with enteral nutrients.

• The mechanism by which gastric bypass leads to a reduction in  ghrelin levels remains to be determined. Our data show thatingested nutrients powerfully regulate the level of circulating ghrelin. Although an empty stomach is associated with an increasedghrelin level in the short term, it is possible that the permanent absence of food in the stomach and duodenum that results fromgastric bypass causes a continuous stimulatory signal that ultimately suppresses ghrelin production through the process of "override inhibition." By this mechanism, continuous gonadotropin-releasing hormone signaling initially stimulates but eventually suppresses gonadotropin secretion,42 and a similar desensitization occurs with the unabated stimulation of growth hormone by growth-hormone–releasing hormone.43 The possibility that override inhibition occurs in the case of ghrelin is suggested by our data showing a progressive decline in the circulating level during an overnight fast (Figure 1 and Figure 2).24

• In summary, 24-hour plasma ghrelin levels increase in response to diet-induced weight loss, suggesting that ghrelin may play a part in the adaptive response that limits the amount of weight that may be lost by dieting. We also found that ghrelin levels are abnormally low after gastric bypass, raising the possibility that this operation reduces weight in part by suppressing ghrelinproduction. These data suggest that ghrelin antagonists may someday be considered in the treatment of obesity.

Malabsorption• Gastric bypass surgery bypasses the section of small bowel in which most vitamins are

digested and absorbed.  Also, as seen below in the excerpts taken from various medical sources, that stapling the stomach can have some repercussions as far as vitamin digestion.

• Vitamin A• Calcium• Vitamin B12

– B12 fact sheet from NIH NOTE: sub lingual or B12 shots are recommended• Vitamin E• Vitamin D

– Vitamin D fact sheet NIH• Polyneuropathy (post stomach stapling)• Selenium Deficiency• Thiamin (vitamin B1 deficiency)• Starvation• Iron

Gastric dumping syndrome• Gastric dumping syndrome, or rapid gastric emptyingis a condition where ingested foods

bypass the stomach too rapidly and enter the small intestine largely undigested. It happens when the upper end of the small intestine, thejejunum, expands too quickly due to the presence of hyperosmolar[jargon] food from the stomach. "Early" dumping begins concurrently or immediately succeeding a meal. Symptoms of early dumping include nausea,vomiting, bloating, cramping, diarrhea, dizziness and fatigue. "Late" dumping happens 1 to 3 hours after eating. Symptoms of late dumping include weakness, sweating, and dizziness. Many people have both types. The syndrome is most often associated with gastric surgery.

• It is speculated that "early" dumping is associated with difficulty digesting fats while "late" dumping is associated with carbohydrates.[citation needed]

• Rapid loading of the small intestine with hypertonic stomach contents can lead to rapid entry of water into the intestinal lumen. Osmotic diarrhea, distension of the small bowel (leading to crampy abdominal pain), and hypovolemia can result.

• In addition, people with this syndrome often suffer from low blood sugar, or hypoglycemia, because the rapid "dumping" of food triggers the pancreas to release excessive amounts of insulin into the bloodstream. This type of hypoglycemia is referred to as "alimentary hypoglycemia".

Gastric bypass• stomach stapled and cut to make new smaller stomach• intestine attached to new stomach• Stomach still makes digestive secretions that mix with bile and pancreatic

secretions• current procedures bypass only onethird of gastrointestinal (GI) tract• possible to achieve weight loss without predisposing patient to nutritional

deficiencies • stomach stapled and cut to make new smaller stomach• intestine attached to new stomach• Stomach still makes digestive secretions that mix with bile and pancreatic

secretions• current procedures bypass only onethird of gastrointestinal (GI) tract• possible to achieve weight loss without predisposing patient to nutritional

deficiencies

Comparing Surgical Procedures for Treatment of Obesity

• What's the best choice: gastric bypass or gastric banding?

• Bariatric surgery is the quickest fix for severe obesity, but patients must carefully weigh benefits and risks before undergoing these invasive procedures. Two reports in 2009 should provide some help with those decisions.

• In a prospective observational cohort study of perioperative complications (JW Gen Med Jul 30 2009), researchers at 10 high-volume U.S. bariatric surgery centers followed nearly 5000 patients who underwent open Roux-en-Y gastric bypass, laparoscopic Roux-en-Y gastric bypass, or laparoscopic adjustable gastric banding. Thirty-day mortality was significantly higher with open bypass than with the other two procedures (2.1% vs. 0.2% and 0%). Incidence of a composite 30-day endpoint (death, venous thromboembolism, operative reintervention, and prolonged hospitalization) was highest with open bypass, intermediate with laparoscopic bypass, and lowest with banding (7.8%, 4.8%, and 1.0%, respectively); this general pattern of complication rates persisted after adjustment for baseline differences between groups. These researchers currently are conducting a study of longer-term outcomes for 2400 patients (LABS-2).

Adjustable gastric banding• band on outside of stomach causes narrowing

• swallowed food fills and stretches narrowed upper stomach and sends signal to brain that entire stomach full

• tubing connects to port placed subcutaneously at midline, just off linea alba

• band tightness adjusted in office by injecting saline into port

Sleeve gastrectomy• new procedure; excises about 80% of stomach along greater

curve• involves neither caloric restriction nor malabsorption• removes hormonal mediators of hunger (eg, ghrelin production

virtually eliminated)• patients never hungry and have no desire to eat• avoids nearly all longterm complications of gastric bypass or

implant, including nutritional deficiencies• preliminary results show efficacy higher than band and slightly

lower than bypass; reduction in risk probably worth benefit

Benefits of weight loss surgery

• much safer than in past

• (mortality rate 0.5%)

• about same as other major surgery (eg, vascular surgery)

Weight reduction• gastric band—European and Australian data

show reduction of 50% to 60% of excess weight;

• data not replicated in United States

• US data show 40% to 45% weight reduction at 3 yr

• gastric bypass— reduction of 65% to 75% of excess weight, mostly in first 18 mo

Diabetes, Hypertension, Sleep Apnea• Diabetes: gastric band—type 2 diabetes improves in about 70%

of patients (complete resolution in some)• Diabetes: gastric bypass—>90% improvement rate• majority cured (usually immediately after surgery and the

reason not totally clear)• Hypertension: gastric band—about 55% improvement rate and

possible cure• gastric bypass—about 75% improvement rate and possible

cure• Sleep apnea: cured in nearly all (98%-99%) patients by both

procedures

Risks• intestinal leaking—can cause peritonitis• Increases death rate from 1 in 200 to 1 in 15• most leaks successfully managed• rarely occurs after banding• occurs in 1% of patients with bypass• pulmonary embolism—1% for both procedures (recent reductions

due to aggressive prophylaxis);• death—nearly 0% with banding; 0.5% with bypass• reoperation rate—4% in both procedures; major complications—

5% after banding; • 5% to 8% after bypass

Follow-up• because of high number of annual procedures, nearly

every physician treats patients with history of bariatric Surgery

• nonabdominal or nonbariatric GI issues addressed as in patients without history of bariatric surgery

• for upper GI complaints in patient with band, first deflate band

• done by primary care physician or bariatric surgeon

• gastric cancer—uncommon, but likely to present at advanced stage (patient complaining of pain)

Follow-up• Biliary disease—endoscopic retrograde

cholangiopancreatography (ERCP) difficult in patients with history of bariatric surger

• gastric bypass causes silent trauma to the liver

• but improves or cures nonalcoholic steatohepatitis (NASH)

• gastric bypass not recommended for patients with active hepatitis B or C

• patient with biliary colic should be referred for gallbladder removal

Complications• early—patients with GI complications <60 days after surgery should be sent

back to bariatric surgeon• most problems surgically related• late complications after banding, most complications implant-related (eg,

infection, breakage, erosion, slippage)• nausea, reflux, or vomiting indicative of complications and should prompt

emptying of band• obtain x-ray• after bypass, most commonly experienced complications include internal hernia,

strictures, and ulcers• pain not normal after bypass• Presence of pain suggestive of complications• Intermittent cramping abdominal pain attributed to internal hernia (most serious

long-term complication) until proven otherwise

Nutritional deficiencies• general malabsorption—food stream has shorter transit

time and less absorptive area

• specific malabsorption—nutrient stream does not contact specific areas of absorption

• iron—after gastric bypass, 50% of premenopausal women develop iron deficiency anemia if not taking supplements

• calcium—two-thirds have altered calcium metabolism (likely vitamin D problem)

• thiamine – uncommon, but serious; may result in peripheral neuropathy (usually irreversible)

Beriberi• Beriberi is a neurological and cardiovascular disease. The three major forms of the

disorder are dry beriberi, wet beriberi, and infantile beriberi.[14]

• Dry beriberi is characterized principally by peripheral neuropathy consisting of symmetric impairment of sensory, motor, and reflex functions affecting distal more than proximal limb segments and causing calf muscle tenderness.[29]

• Wet beriberi is associated with mental confusion, muscular wasting, edema, tachycardia, cardiomegaly, and congestive heart failure in addition to peripheral neuropathy.[2]

• Infantile beriberi occurs in infants breast-fed by thiamin-deficient mothers (who may show no sign of thiamine deficiency). Infants may manifest cardiac, aphonic, or pseudomeningitic forms of the disorder. Infants with cardiac beriberi frequently exhibit a loud piercing cry, vomiting, and tachycardia.[14] Convulsions are not uncommon, and death may ensue if thiamine is not administered promptly.[29]

• Following thiamine treatment, rapid improvement occurs generally within 24 hours.[14] Improvements of peripheral neuropathy may require several months of thiamine treatment.

Alcoholic brain disease• Nerve cells and other supporting cells (such as glial cells) of the nervous system require thiamine. Examples of neurologic disorders

that are linked to alcohol abuse include Wernicke’s encephalopathy (WE, Wernicke-Korsakoff syndrome) and Korsakoff’s psychosis (alcohol amnestic disorder) as well as varying degrees of cognitive impairment. [33]

• Wernicke’s encephalopathy is the most frequently encountered manifestation of thiamine deficiency in Western society, [34] though it may also occur in patients with impaired nutrition from other causes, such as gastrointestinal disease, [34] those with HIV-AIDS, and with the injudicious administration of parenteral glucose or hyperalimentation without adequate B-vitamin supplementation. [35] This is a striking neuro-psychiatric disorder characterized by paralysis of eye movements, abnormal stance and gait, and markedly deranged mental function.[36]

• Alcoholics may have thiamine deficiency because of the following:

• inadequate nutritional intake: alcoholics tend to intake less than the recommended amount of thiamine.

• decreased uptake of thiamine from the GI tract: active transport of thiamine into enterocytes is disturbed during acute alcohol exposure.

• liver thiamine stores are reduced due to hepatic steatosis or fibrosis. [37]

• impaired thiamine utilization: magnesium, which is required for the binding of thiamine to thiamine-using enzymes within the cell, is also deficient due to chronic alcohol consumption. The inefficient utilization of any thiamine that does reach the cells will further exacerbate the thiamine deficiency.

• Ethanol per se inhibits thiamine transport in the gastrointestinal system and blocks phosphorylation of thiamine to its cofactor form (ThDP).[38]

• Korsakoff Psychosis is generally considered to occur with deterioration of brain function in patients initially diagnosed with WE. [39]. This is an amnestic-confabulatory syndrome characterized by retrograde and anterograde amnesia, impairment of conceptual functions, and decreased spontaneity and initiative.< [29]

• Following improved nutrition and the removal of alcohol consumption, some impairments linked with thiamine deficiency are reversed; particularly poor brain functionality, although in more severe cases, Wernicke-Korsakoff syndrome leaves permanent damage.

Nutritional deficiencies• fat-soluble vitamins (A, D, E, K) deficiencies develop slowly

• vitamin B12 requires laboratory testing

• 30% of bariatric procedure patients deficient in vitamin B12

• most asymptomatic

• protein—not true malabsorptive deficiency; postoperatively

• body’s use of fat and amino acids for energy and wastes protein;

• recommendations—daily multivitamin usually sufficient to resolve or prevent vitamin deficiencies;

• prescribe 2 chewable vitamins (18 mg of iron per tablet) and 1200 mg calcium with 400 IU vitamin D (eg, 2 Caltrate D tablets) daily

• 70 to 80 g of protein per day by supplementation during acute weight loss phase

• check serum levels frequently during rapid weight loss and annually thereafter

• recommend routinely checking calcium, vitamins A, B1, B9, B12, D, E, and K, zinc, iron, and magnesium

• start on multivitamin and thiamine (pending test results)

Other primary care issues• stabbing pain (usually subxiphoid) likely ulcer• treat with proton pump inhibitor• Serious cases may require liquid sucralfate (Carafate)• Severe pain surgical emergency• wide variability among patients, especially those who

underwent surgery >5 yr ago• when referring for bariatric surgery, most important

factors are surgeon’s experience and multidisciplinary team (especially dietician)

The latest findings confirm that obesity will soon overtake

tobacco use as the leading cause of

preventable death in the United States.

(A) True (B) False

Answer

• (B) False

Which of the following diets was shown to be

effective for weight loss?(A) Atkins diet (B) Ornish diet (C) Zone diet

(D) All the above

Answer

• (D) All the above

All the following are elements of successful maintenance of weight

loss, except:(A) High level of physical

activity (B) Reduced caloric intake

(C) Regular self-monitoring of weight

(D) Weight loss medications

Answer

• (D) Weight loss medications

Gastric bypass is _________ the best dietary

intervention.(A) As effective as

(B) Twice as effective as (C) Five times more

effective than(D) Less effective than

Answer

• (B) Twice as effective as

Bariatric surgery has been shown to improve or cure which of the

following?1. Diabetes

2. Hypertension3. Sleep apnea

(A) 1 (B) 1,2 (C) 1,3 (D) 1,2,3

Answer

• 1. Diabetes

• 2. Hypertension

• 3. Sleep apnea

• (D) 1,2,3

The National Institutes of Health (NIH) recommends weight loss surgery for individuals with a

bodymass index of _______ if the patient also has hypertension, heart disease, sleep apnea, or

diabetes.(A) 30 (B) 35 (C) 40 (D)

45

Answer

• (B) greater than 35

The first step in addressing any upper gastrointestinal complaint in a patient who

has had gastric bandingshould be deflation of the

band.(A) True (B) False

Answer

• (A) True

Gastric bypass causes silent trauma to the:

(A) Kidneys (B) Liver (C) Heart (D) Pancreas

Answer

• (B) Liver

Gastric bypass is not recommended in patients with

which of the following?(A) Active hepatitis B (B) Active hepatitis C

(C) Nonalcoholic steatohepatitis(D) A and B

Peripheral neuropathy may result from deficiency of which of the

following?(A) Thiamine (B) Vitamin D

(C) Calcium (D) Vitamin B12

(E) A and D

Answer

•(A) Thiamine B1 (D) Vitamin B12 (E) A and D