treatment of obesity pennington biomedical research center division of education

Treatment of Treatment of ObesityObesity

Pennington Biomedical Research Pennington Biomedical Research Center Center

Division of EducationDivision of Education

20092009 22

Treatment optionsTreatment options

When does obesity threaten the health When does obesity threaten the health and life of a patient?and life of a patient?

Which patients have co-morbidities Which patients have co-morbidities that make an aggressive treatment that make an aggressive treatment necessary? necessary?

20092009 33

Steps in determining Steps in determining treatmenttreatment

Determine BMI.Determine BMI.

Assess complications and risk factorsAssess complications and risk factors

20092009 44


Determine BMI-related health riskDetermine BMI-related health risk Determine weight reduction Determine weight reduction

exclusionsexclusions Mental illnessMental illness Unstable medical conditionUnstable medical condition Some medicationsSome medications TemporaryTemporary

Pregnancy or lactationPregnancy or lactation

20092009 55


Possible exclusionsPossible exclusions OsteoporosisOsteoporosis BMI in minimal or no-risk categoryBMI in minimal or no-risk category History of mental illnessHistory of mental illness MedicationsMedications

Permanent exclusionsPermanent exclusions Anorexia nervosaAnorexia nervosa Terminal illnessTerminal illness

Assess patient readinessAssess patient readiness

20092009 66


Treatment OptionsTreatment Options 1. 1. Mild energy-deficit regimenMild energy-deficit regimen

Diet, diet and exercise, behavioral therapyDiet, diet and exercise, behavioral therapy

2. 2. Aggressive energy-deficit regimenAggressive energy-deficit regimenVLCDVLCD

Extensive exercise programExtensive exercise program

3. 3. Obesity drugsObesity drugs

4.4. Surgery Surgery More extreme options

20092009 77

Dietary treatmentDietary treatment

When someone is a few pounds overweight When someone is a few pounds overweight and is motivated to lose weight, dietary and is motivated to lose weight, dietary approach is a safe and effective method for approach is a safe and effective method for weight loss. It is also the best method for weight loss. It is also the best method for helping to acquire new skills for maintaining helping to acquire new skills for maintaining a weight loss. a weight loss.

20092009 88

Dieting with the Exchange Dieting with the Exchange ListList

The The Exchange dietExchange diet.. Monitor intake of carbohydrates, fat Monitor intake of carbohydrates, fat

and protein as well as portion sizes.and protein as well as portion sizes. Includes foods from each group and Includes foods from each group and

can be used indefinitely.can be used indefinitely. It also works well in weight It also works well in weight

maintenance.maintenance.

20092009 99

Dieting with the Exchange ListDieting with the Exchange List

Food is broken down into 6 categories:Food is broken down into 6 categories:

Starch/BreadStarch/Bread

MeatMeat

VegetablesVegetables

FruitFruit

MilkMilk

FatFat

20092009 1010

The Exchange ListThe Exchange List

The number of exchanges is The number of exchanges is determined by the total number of determined by the total number of calories required.calories required.

Different for each person and Different for each person and depends on:depends on: height, weight, and energy expenditure.height, weight, and energy expenditure.

1111

Exchanges for Various Calorie Exchanges for Various Calorie LevelsLevels

Total Total Kcal/Kcal/dd

12001200 14001400 15001500 16001600 17001700 18001800 20002000 21002100 22002200

MeatMeat 44 44 55 66 66 66 66 66 66Bread/Bread/

starchstarch55 77 77 77 88 99 1010 1111 1111

VegsVegs 22 33 44 22 22 22 22 22 33FatsFats 33 33 33 33 33 44 44 44 44FruitFruit 33 33 33 33 33 33 33 33 44Skim Skim milk milk (cups)(cups)

22 22 22 -- -- -- -- -- --

2% 2% milkmilk 22 22 22 22 22 33

20092009 1212

Example of daily exchange Example of daily exchange diet: 1800 Kcals dailydiet: 1800 Kcals daily

1 c orange juice1 c orange juice

2 slices of toast2 slices of toast

1 hard-cooked egg1 hard-cooked egg

2 tsp margarine2 tsp margarine

1 c 2% milk1 c 2% milk

Coffee or teaCoffee or tea

2 Fruits2 Fruits

2 Breads2 Breads

1 Meat1 Meat

2 Fat2 Fat

1 Milk1 Milk

Free FoodFree Food

Yields

BREAKFASTBREAKFAST

20092009 1313


½ c tuna½ c tuna

2 slices whole wheat bread2 slices whole wheat bread

½ c tomato slices½ c tomato slices

Lettuce/cucumber salad Lettuce/cucumber salad

1 c sliced peaches1 c sliced peaches


Tea with lemonTea with lemon

2 Meat2 Meat

2 Bread2 Bread

1 Vegetable1 Vegetable

Raw VegetableRaw Vegetable

2 Fruit2 Fruit

2 Fat2 Fat

Free FoodsFree Foods

Yields

LUNCHLUNCH

20092009 1414


3 oz baked chicken3 oz baked chicken

½ c mashed potato ½ c mashed potato

1 small whole grain roll1 small whole grain roll

½ c broccoli, ½ c carrots½ c broccoli, ½ c carrots

Tossed saladTossed salad

1 Tbsp salad dressing 1 Tbsp salad dressing


CoffeeCoffee

3 meat3 meat

1 Bread1 Bread

1 Bread1 Bread

1 Vegetable1 Vegetable

Raw VegetableRaw Vegetable

1 Fat1 Fat

1 Fat 1 Fat

Free FoodFree Food

Yields

DINNERDINNER

20092009 1515


2 graham crackers2 graham crackers

1 c 2% milk 1 c 2% milk

1 Bread1 Bread

1 Milk1 Milk

EVENING EVENING SNACKSNACK

20092009 1616

The Exchange DietThe Exchange Diet

For more information please visit:For more information please visit:

http://www.diabetes.org/home.jsp

20092009 1717

Dieting Using Calorie Dieting Using Calorie Controlled PortionsControlled Portions

MEAL REPLACEMENT PLANMEAL REPLACEMENT PLAN

Liquid formula or a packaged item Liquid formula or a packaged item Fixed number of calories to replace a meal.Fixed number of calories to replace a meal.

Control portion sizes Control portion sizes Fat, carbohydrate, caloriesFat, carbohydrate, calories

Balanced mealsBalanced meals

20092009 1818

Meal Replacement PlanMeal Replacement Plan

4 types of meal replacers:4 types of meal replacers:Powder mixesPowder mixes

ShakesShakes

BarsBars

Prepackaged MealsPrepackaged Meals

20092009 1919

Meal Replacement PlanMeal Replacement Plan

An intake of An intake of fivefive fruits and vegetables is fruits and vegetables is recommended.recommended.

Effective Effective ConvenientConvenient Nutritionally balanced Nutritionally balanced

20092009 2020

Example:Example:A MEAL REPLACEMENT PLANA MEAL REPLACEMENT PLAN

BreakfastBreakfast Meal ReplacementMeal Replacement

LunchLunch Sensible Meal or Meal Sensible Meal or Meal ReplacementReplacement

DinnerDinner Sensible MealSensible Meal

SnacksSnacks Fruit, vegetable, fat-Fruit, vegetable, fat-free yogurt or cheese, free yogurt or cheese, nuts, pretzels, or air-nuts, pretzels, or air-

popped popcorn popped popcorn

20092009 2121

ExerciseExercise

Adults: Adults: 30-45 minutes30-45 minutes of exercise of exercise three to five daysthree to five days each weekeach week

Include 5-10 minute warm up and cool downInclude 5-10 minute warm up and cool down

Weight loss: at least Weight loss: at least 30 minutes of aerobic activity a 30 minutes of aerobic activity a dayday for five days for five days

20092009 2222

ExerciseExercise

Children: at least 60 minutes, and up to several Children: at least 60 minutes, and up to several hours of physical activity per day for children and hours of physical activity per day for children and adolescentsadolescents

Several bouts of physical activity lasting 15 Several bouts of physical activity lasting 15 minutes or more each dayminutes or more each day

20092009 2323

ExerciseExercise

Energy Balance = maintaining Energy Balance = maintaining weightweight. .

Positive energy balance leads to Positive energy balance leads to weight gain.weight gain.

Negative energy balance leads to Negative energy balance leads to weight loss.weight loss.

20092009 2424

Exercise: Exercise: BenefitsBenefits

Exercise builds lean body mass.

Walking, running and doing physical activity can burn two to three times more calories

than similar amount of time sitting.

With exercise there is an improvement in overall physical fitness.

Exercise improves maintenance of weight after weight loss.

20092009 2525

ExerciseExercise

For Weight LossFor Weight Loss 150 to 200 minutes of moderate physical activity

each week diet for weight loss

For For Improved HealthImproved Health

An exercise program with less than 150 minutes a week and lower intensity can result in improvement

in cardio-respiratory fitness.

20092009 2626

Aerobic ActivityAerobic Activity

Aerobic exercise is any extended activity that makes the lungs and heart work harder while using the large muscle

groups in the arms and legs at a regular, even pace.

EXAMPLES EXAMPLES

Brisk walking Jogging Bicycling Swimming Aerobic dancing

Racket sports Lawn mowing

Ice or roller skating Using aerobic equipment

(treadmill, stationary bike)

20092009 2727

Anaerobic ActivityAnaerobic Activity

Anaerobic activity is short bursts of very strenuous activity using large muscle groups

(Ex: weight lifting, curls, power lifting).

Helps build and tone muscles, but it does not benefit the heart or the lungs.

20092009 2828

Very Low Calorie Diets Very Low Calorie Diets (VLCD)(VLCD)

Formula diet of 800 calories or less.Formula diet of 800 calories or less. Must be under proper medical Must be under proper medical

supervision.supervision. Produce significant weight loss in Produce significant weight loss in

moderately to severely obese patients. moderately to severely obese patients.

20092009 2929

VLCD: VLCD: FactsFacts

Not recommended for pregnant or breastfeeding Not recommended for pregnant or breastfeeding womenwomen

Not appropriate for children or adolescentsNot appropriate for children or adolescents Not recommended for older individualsNot recommended for older individuals

20092009 3030

Behavioral TreatmentBehavioral Treatment

Widely used strategyWidely used strategy

Based on adjusting energy balance Based on adjusting energy balance

Individual treatment, orIndividual treatment, or

Group FormatGroup Format (Around 18-24 weeks)(Around 18-24 weeks)

One of the most successful One of the most successful treatment programstreatment programs

20092009 3131

Group ApproachesGroup Approaches

Social supportSocial support integration into social network and positive integration into social network and positive

interactions with others.interactions with others. Individual feels support, acceptance, and Individual feels support, acceptance, and

encouragement by others.encouragement by others.

20092009 3232

Behavior TreatmentBehavior Treatment

Need to change one’s Need to change one’s approach approach thinkingthinking feelings feelings actions actions

to eating and physical activity.to eating and physical activity.

20092009 3333

Behavioral targetsBehavioral targets

WeightWeight =Total energyintake

Total energy expenditure

_

EatingEating ActivityActivity

Targets of behavioral therapy

20092009 3434

Behavior Therapy: Behavior Therapy: Important ComponentsImportant Components

1.1. Making Lifestyle Change a PriorityMaking Lifestyle Change a Priority

2.2. Establishing a Plan for SuccessEstablishing a Plan for Success

20092009 3535

Behavior Therapy: Behavior Therapy: Important ComponentsImportant Components

3.3. Setting GoalsSetting Goals Calories, fat, physical activity.Calories, fat, physical activity. Short-term goal of losing 1 to 2 pounds a week. Short-term goal of losing 1 to 2 pounds a week. ChooseChoose specific, attainable, and realisticspecific, attainable, and realistic goals. goals. Have a long-term goal. Have a long-term goal.

20092009 3636

Behavior Therapy: Behavior Therapy: Important ConceptsImportant Concepts

4. 4. Keeping Track of Eating and ExercisingKeeping Track of Eating and Exercising Tracking to raise awareness.Tracking to raise awareness. Self monitoringSelf monitoring.. Record time, activating event, place and quantity of Record time, activating event, place and quantity of

eating, and activity behaviors.eating, and activity behaviors.

20092009 3737


5. 5. Avoiding a Food Chain ReactionAvoiding a Food Chain Reaction

Stimulus control.Stimulus control.

Learning to recognize cues. Learning to recognize cues.

20092009 3838


Techniques to conquer eating triggers include:Techniques to conquer eating triggers include: eating regular mealseating regular meals eating at the same time and placeeating at the same time and place use smaller platesuse smaller plates keeping accessible food out of sightkeeping accessible food out of sight eating only when hungry eating only when hungry avoiding activities that encourage eatingavoiding activities that encourage eating

20092009 3939


6. 6. Changing Eating and Activity PatternsChanging Eating and Activity Patterns

slowing pace of eatingslowing pace of eating reducing portion sizes reducing portion sizes measuring food intakemeasuring food intake leaving food on plateleaving food on plate improving food choicesimproving food choices eliminating second servings eliminating second servings

20092009 4040


Changing Eating and Activity PatternsChanging Eating and Activity Patterns

Programmed exercise vs lifestyleProgrammed exercise vs lifestyle Lifestyle activity preferable for weight Lifestyle activity preferable for weight

loss.loss.

20092009 4141


7. 7. Contingency ManagementContingency Management Positive reinforcement (reward) Positive reinforcement (reward)

An effective reward - immediate, desirable, and given An effective reward - immediate, desirable, and given based on meeting a specific goal. based on meeting a specific goal.

Tangible rewards - a new CDTangible rewards - a new CD Intangible reward – taking time off Intangible reward – taking time off

20092009 4242


8. 8. Cognitive Behavioral StrategiesCognitive Behavioral Strategies Traditional behavioral treatment components Traditional behavioral treatment components

with emphasis on thinking patterns that may with emphasis on thinking patterns that may affect eating behaviors.affect eating behaviors.

20092009 4343


9. 9. Stress ManagementStress Management

Stress is a primary predictor of Stress is a primary predictor of overeating and relapse.overeating and relapse.

Stress management skills Stress management skills

20092009 4444

Drug Treatment of Drug Treatment of Obesity:Obesity: Indicated whenIndicated when

BMI is greater than 30BMI is greater than 30 BMI is higher than 27 and there are BMI is higher than 27 and there are

other cardiovascular complications other cardiovascular complications After several attempts diet alone is After several attempts diet alone is

not enoughnot enough

Cardiovascular complications include: Hypertension, Dyslipidemia, Coronary Heart Disease, Type 2 Diabetes, and Sleep Apnea

20092009 4545

Drug TherapyDrug Therapy

Commonly prescribed drugs for the Commonly prescribed drugs for the treatment of obesity include:treatment of obesity include:

PhenterminePhentermine

SibutramineSibutramine

OrlistatOrlistat

20092009 4646

Drug Therapy: Drug Therapy: PhenterminePhentermine

Brand names are Brand names are Adipex-P, Obenix, Oby-TrimAdipex-P, Obenix, Oby-Trim Most commonly prescribed medication for weight Most commonly prescribed medication for weight

loss.loss.

Phentermine increases norepinephrine, a Phentermine increases norepinephrine, a neurotransmitter in the brain that decreases neurotransmitter in the brain that decreases

appetite. appetite.

Phentermine has stimulant properties, and it may cause high blood pressure or irregular heat beats.

20092009 4747

Drug Therapy: Drug Therapy: SibutramineSibutramine

The brand name is MeridiaThe brand name is Meridia

Sibutramine induces weight loss by reducing food intake. Sibutramine induces weight loss by reducing food intake. It stimulates the

satiety centers in the brain.

Sibutramine use may Sibutramine use may increaseincrease heart rate and blood heart rate and blood pressure.pressure.

Sibutramine is not recommended for someone with Sibutramine is not recommended for someone with uncontrolled hypertension, tachycardia, or serious uncontrolled hypertension, tachycardia, or serious

heart, liver, or kidney disease. heart, liver, or kidney disease.

20092009 4848

Drug Therapy:Drug Therapy: OrlistatOrlistat

The Brand name is The Brand name is XenicalXenical

Orlistat prevents the digestion of dietary fat.

Bowel habits will likely change.Bowel habits will likely change.

Leads to improvement in blood lipids.Leads to improvement in blood lipids.

Multivitamin supplement is encouraged.Multivitamin supplement is encouraged.

20092009 4949

Surgical Treatment of Surgical Treatment of ObesityObesity

Criteria used for surgical treatmentCriteria used for surgical treatment::

BMI is 40 or higher BMI is 40 or higher

BMI of 35-39.9 and a serious obesity-related BMI of 35-39.9 and a serious obesity-related health problemhealth problem

such assuch as: Type 2 diabetes, hypertension, heart : Type 2 diabetes, hypertension, heart disease, or sleep apneadisease, or sleep apnea

20092009 5050

Types of GI surgeries Types of GI surgeries availableavailable

RestrictiveRestrictive

MalabsorptiveMalabsorptive

Combined restrictive/malabsorptiveCombined restrictive/malabsorptive

20092009 5151

GI Surgeries: RestrictiveGI Surgeries: Restrictive

Purely restrictive operations only limit food intake and do not interfere with the normal digestive process.

Create a pouch. Create a pouch.

Delay in food emptying. Delay in food emptying.

20092009 5252

Restrictive Operations: Restrictive Operations: ExamplesExamples

1.1. Adjustable gastric bandingAdjustable gastric banding

A band is clamped to create a pouch. A band is clamped to create a pouch.

20092009 5353

Restrictive Operations: Restrictive Operations: ExamplesExamples

2. Vertical banded gastroplasty.2. Vertical banded gastroplasty.

Uses the band and staples to createUses the band and staples to create

a small pouch. Not commonly useda small pouch. Not commonly used

today. today.

20092009 5454

Restrictive Operations: Restrictive Operations: AdvantagesAdvantages

1.1. Generally safer than malabsorptive Generally safer than malabsorptive procedures.procedures.

2.2. Done via laparoscopy allowing for Done via laparoscopy allowing for smaller incisions.smaller incisions.

3.3. Surgeries can be reversed if necessary.Surgeries can be reversed if necessary.

4.4. Result in few nutritional deficiencies. Result in few nutritional deficiencies.

20092009 5555

Restrictive Operations: Restrictive Operations: DisadvantagesDisadvantages

1.1. Smaller weight loss.Smaller weight loss.

2.2. Can lead to weight gain over time.Can lead to weight gain over time.

3.3. No change in eating habits.No change in eating habits.

4.4. Success depends on the patient’s Success depends on the patient’s willingness to adopt a healthy willingness to adopt a healthy lifestyle.lifestyle.

20092009 5656

Restrictive Operations: Restrictive Operations: RisksRisks

1.1. Overeating leading to vomiting.Overeating leading to vomiting.2.2. Break in tubing.Break in tubing.3.3. Problems leading to a second operation.Problems leading to a second operation.

These risks need to be taken into account by any individual considering the

surgery!

20092009 5757

Malabsorptive OperationsMalabsorptive Operations

The main malabsorptive operation is the The main malabsorptive operation is the jejunoileal bypass jejunoileal bypass which is not which is not performed today because of the high performed today because of the high incidence of health complications. incidence of health complications.

20092009 5858

Combined Restrictive and Combined Restrictive and Malabsorptive OperationsMalabsorptive Operations

Restricts both food intake and the amount of Restricts both food intake and the amount of calories and nutrients the body absorbs.calories and nutrients the body absorbs.

Roux-en-Y gastric bypass (RGB) (RGB)Creates a pouch. Creates a pouch. Connects the small intestineConnects the small intestineto the pouch, bypassing large to the pouch, bypassing large sections of the intestines.sections of the intestines.

20092009 5959

Combined Restrictive and Combined Restrictive and

Malabsorptive OperationsMalabsorptive Operations

Biliopancreatic diversion (BPD)

Remove portion of stomach. Remove portion of stomach.

Connect this directly to theConnect this directly to the

final segment of the small intestinefinal segment of the small intestine

completely bypassing sections of completely bypassing sections of

intestines. intestines.

20092009 6060

Combined Operations: Combined Operations: AdvantagesAdvantages

1.1. Rapid weight loss.Rapid weight loss.

2.2. Maintain good weight loss for 10 years or Maintain good weight loss for 10 years or more.more.

3.3. Can lose up to 75-80% of excess weight.Can lose up to 75-80% of excess weight.

4.4. May lead to greater improvement in May lead to greater improvement in health. health.

20092009 6161

Combined Operations: Combined Operations: DisadvantagesDisadvantages

1.1. Can be difficult. Can be difficult. 2.2. May result in long-term nutritional May result in long-term nutritional

deficiencies.deficiencies.3.3. Decreased absorption of iron and calcium.Decreased absorption of iron and calcium.4.4. Require fat soluble vitamin Require fat soluble vitamin

supplementation.supplementation.5.5. May have dumping syndrome.May have dumping syndrome.

20092009 6262

Combined Operations: Combined Operations: RisksRisks

1.1. May lead to complications.May lead to complications.

2.2. Greater risk for abdominal hernias.Greater risk for abdominal hernias.

3.3. The risk of death may be higher.The risk of death may be higher.

20092009 6363

Bariatric Surgery: Bariatric Surgery: FactsFacts

Procedures cost from $20,000 to $35,000. Procedures cost from $20,000 to $35,000.

Medical insurance coverage varies by state.Medical insurance coverage varies by state.

20092009 6464

NIDDKNIDDK (National Institute of Diabetes and Digestive (National Institute of Diabetes and Digestive and Kidney Diseases)and Kidney Diseases)

The patient should consider the following The patient should consider the following questions prior to weight loss surgery:questions prior to weight loss surgery:

1.1. Are you unlikely to lose weight or keep weight Are you unlikely to lose weight or keep weight off long-term with non-surgical measures?off long-term with non-surgical measures?

2.2. Are you well informed about the surgical Are you well informed about the surgical procedure and the effects of treatment?procedure and the effects of treatment?

3.3. Are you determined to lose weight and Are you determined to lose weight and improve your health?improve your health?

20092009 6565

NIDDKNIDDK

4. Are you aware of how your life may change 4. Are you aware of how your life may change after the operation?after the operation?

5. Are you aware of the potential for serious 5. Are you aware of the potential for serious complications, dietary restrictions, and complications, dietary restrictions, and occasional failures? occasional failures?

6. Are you committed to lifelong medical follow-6. Are you committed to lifelong medical follow-up and vitamin/mineral supplementation?up and vitamin/mineral supplementation?

20092009 6666

ConclusionsConclusions

When there are no complications or co-When there are no complications or co-morbidities associated with obesity, morbidities associated with obesity, dietary, exercise and behavioral dietary, exercise and behavioral approaches are the safest and best approaches are the safest and best approaches. approaches.

For successful weight loss to become For successful weight loss to become permanent, an individual has to adopt new permanent, an individual has to adopt new behaviors to maintain weight loss. behaviors to maintain weight loss.

20092009 6767

ConclusionConclusion

It is very important for individuals considering It is very important for individuals considering initiation of weight loss drug therapy or surgeries initiation of weight loss drug therapy or surgeries to be well aware of the risks associated with the to be well aware of the risks associated with the treatments.treatments.

Once all risks are understood, then ultimately it Once all risks are understood, then ultimately it is the individual’s decision to go along with the is the individual’s decision to go along with the treatment or not.treatment or not.

20092009 6868

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Foreyt, J.P., & Poston, W.S.C., Jr. (1998b). What is the role of Foreyt, J.P., & Poston, W.S.C., Jr. (1998b). What is the role of cognitive-behavior therapy in patient management? cognitive-behavior therapy in patient management? Obes Res, Obes Res, 66(Supplement 1), 18S-22S(Supplement 1), 18S-22S

Foster, G.D., Wadden, T.A., Vogt, R.A., & Brewer, G. (1997). Foster, G.D., Wadden, T.A., Vogt, R.A., & Brewer, G. (1997). What is a reasonable weight loss? Patients' expectations and What is a reasonable weight loss? Patients' expectations and evaluations of obesity treatment outcomes. evaluations of obesity treatment outcomes. J Consult Clin J Consult Clin Psychol, 65Psychol, 65, 79-85, 79-85

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Poston, W.S.C., Jr., Hyder, M.L., O'Byrne, K.K., & Foreyt, J.P. Poston, W.S.C., Jr., Hyder, M.L., O'Byrne, K.K., & Foreyt, J.P. (2000). (2000). Where do diets, exercise, and behavior modification fit Where do diets, exercise, and behavior modification fit in the treatment of obesity? in the treatment of obesity? Endocrine, 13Endocrine, 13(2), 187-192.(2), 187-192.

Wadden, T.A., Sarwer, D.B., & Berkowitz, R.I. (1999). Wadden, T.A., Sarwer, D.B., & Berkowitz, R.I. (1999). Behavioural treatment of the overweight patient. Behavioural treatment of the overweight patient. Baillieres Baillieres Best Pract Res Clin Endocrinol Metab, 13Best Pract Res Clin Endocrinol Metab, 13(1), 93-107.(1), 93-107.

Wing, R.R. (1993). Behavioral approaches to the treatment of Wing, R.R. (1993). Behavioral approaches to the treatment of obesity. In G. Bray, C. Bouchard & P. James (Eds.), obesity. In G. Bray, C. Bouchard & P. James (Eds.), Handbook of ObesityHandbook of Obesity (pp. 855-873). New York: Marcel (pp. 855-873). New York: Marcel Dekker, Inc.Dekker, Inc.

Wing, R.R., & Tate, D.F. (2002). Behavior modification for Wing, R.R., & Tate, D.F. (2002). Behavior modification for obesity. In J.F. Caro (Ed.), obesity. In J.F. Caro (Ed.), ObesityObesity. . http://www.endotext.org/obesity/index.htm:http://www.endotext.org/obesity/index.htm:

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http://www.cdc.gov http://www.cdc.gov National Heart, Lung, and Blood Institute, Clinical Guidelines National Heart, Lung, and Blood Institute, Clinical Guidelines

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Obesity Management 1: 15-19, 2005.Obesity Management 1: 15-19, 2005. Greenway, F. Surgery for obesity. Endocrinology and Greenway, F. Surgery for obesity. Endocrinology and

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McArdle WD, Katch FL, and Katch VL. Exercise Physiology: McArdle WD, Katch FL, and Katch VL. Exercise Physiology: Energy, Nutrition and Human Performance, 5th Edition. Energy, Nutrition and Human Performance, 5th Edition. Lippincott Lippincott Williams & Wilkins 2004.Williams & Wilkins 2004.

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References: References: DietDiet http://www.cdc.govhttp://www.cdc.gov Noakes M, Foster PR, Keogh JB, Clifton PM. Noakes M, Foster PR, Keogh JB, Clifton PM. Meal replacements are as Meal replacements are as

effective as structured weight-loss diets for treating obesity in adults with effective as structured weight-loss diets for treating obesity in adults with features of metabolic syndrome. features of metabolic syndrome. J Nutr. 2004 Aug;134(8):1894-9.J Nutr. 2004 Aug;134(8):1894-9.

Truby H, Millward D, Morgan L, Fox K, Livingstone MB, DeLooy A, Truby H, Millward D, Morgan L, Fox K, Livingstone MB, DeLooy A, Macdonald I. A randomised controlled trial of 4 different commercial Macdonald I. A randomised controlled trial of 4 different commercial weight loss programmes in the UK in obese adults: body composition weight loss programmes in the UK in obese adults: body composition changes over 6 months.changes over 6 months.Asia Pac J Clin Nutr. 2004 Aug;13(Suppl):S146.Asia Pac J Clin Nutr. 2004 Aug;13(Suppl):S146.

http://www.slim-fast.com/plan/index.asp?bhcp=1 Accessed September http://www.slim-fast.com/plan/index.asp?bhcp=1 Accessed September 16, 2004.16, 2004.

Halford JCG, Ball MF, Pontin EE, Maharjan LB, Dovey TM, Pinkney JH, Halford JCG, Ball MF, Pontin EE, Maharjan LB, Dovey TM, Pinkney JH, Wilding JPH, Mela DJ. The impact of using meal-replacements versus Wilding JPH, Mela DJ. The impact of using meal-replacements versus standard dietetic advice on body weight, appetite, mood, and satisfaction standard dietetic advice on body weight, appetite, mood, and satisfaction during a 12-week weight control. North American Association for the during a 12-week weight control. North American Association for the Study of Obesity Conference, November 14-18, 2004, Las Vegas, Study of Obesity Conference, November 14-18, 2004, Las Vegas, Nevada.Nevada.

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Pennington Biomedical Pennington Biomedical Research CenterResearch Center

Division of EducationDivision of Education Heli J. Roy, PhD, RDHeli J. Roy, PhD, RD Beth KalickiBeth Kalicki Division of EducationDivision of Education

Phillip Brantley, PhD, DirectorPhillip Brantley, PhD, DirectorPennington Biomedical Research Pennington Biomedical Research CenterCenterClaude Bouchard, PhD, Executive Claude Bouchard, PhD, Executive DirectorDirector

Edited: October 2009

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About Our Company…About Our Company…The Pennington Biomedical Research Center is a world-renowned nutrition research center. Mission:To promote healthier lives through research and education in nutrition and preventive medicine. The Pennington Center has several research areas, including: Clinical Obesity ResearchExperimental ObesityFunctional FoodsHealth and Performance EnhancementNutrition and Chronic DiseasesNutrition and the BrainDementia, Alzheimer’s and healthy agingDiet, exercise, weight loss and weight loss maintenance The research fostered in these areas can have a profound impact on healthy living and on the prevention of common chronic diseases, such as heart disease, cancer, diabetes, hypertension and osteoporosis. The Division of Education provides education and information to the scientific community and the public about research findings, training programs and research areas, and coordinates educational events for the public on various health issues. We invite people of all ages and backgrounds to participate in the exciting research studies being conducted at the Pennington Center in Baton Rouge, Louisiana. If you would like to take part, visit the clinical trials web page at www.pbrc.edu or call (225) 763-3000.

treatment of obesity pennington biomedical research center division of education

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