Nutrition ScienceePolicy
November 1992: 338-345
Editorial Treatment of 0besity Richard L. Atkinson, M.D. In March, 1992, an NIH Technology Assessment Conference was held in Bethesda, Maryland, on the topic of “Methods for Voluntary Weight Loss and Control.” During this Conference, a series of questions was addressed.’ Some of these questions were: 1. How often and in what ways do Americans try to lose weight? 2. How successful are various methods for weight loss and control? What are the attributes of and barriers to successful weight loss methods/ approaches? 3. What are the short- and long-term benefits and adverse effects of weight loss? It is apparent that a large percentage of Americans are attempting to lose weight by a variety of methods. Obesity is a major public health problem in America, since 25 to 34% of adult Americans fulfill the criteria for obesity.2 Obesity is associated with numerous health problems, including diabetes mellitus, hypertension, hyperlipidemia, atherosclerotic disease, sleep apnea, gallbladder disease, and some types of cancer. Federal surveys have shown that from 33 to 40% of adult women and from 20 to 24% of adult men are currently trying to lose weight. Most obese individuals have attempted weight loss on several occasions, and a large industry has appeared to assist them. Commercial weight reduction programs and many community hospital programs have developed in recent years and estimates range as high as 30 to 40 billion dollars per year spent on weight reduction. With this massive effort, abuses occur, and 14% of female students admit to using self-induced vomiting in an attempt to lose weight.
Dr. Atkinson is at the Veterans Affairs Medical Center, Department of Internal Medicine, Eastern Virginia Medical School, Hampton, VA 23667.
338
Self-imposed diets and exercise are the most frequently used methods for weight control, but vitamins, diet supplements, and obesity medications are used by substantial numbers of people. The combination of diet, exercise, and behavior modification of lifestyle and eating habits is the approach recommended by most health professionals in the field. Unfortunately, this approach to weight control is difficult for most people to follow for the long term, and weight regain is frequent. Wadden et aL3 has shown that if no other treatment is given, less than 5% of individuals maintain weight loss for five years after completion of a comprehensive weight reduction program. The low success rate in people who are treated in university weight control programs may not be representative of the general population, as the proportion who have been unable to lose weight on their own is increased. The Expert Panel at the Technology Assessment Conference noted the paucity of long term studies, and recommended more research in the general population as well as in selected populations to identify the factors associated with success. Very low calorie diets (VLCD) for obesity are somewhat controversial, but since VLCD are part of many commercial weight reduction programs, millions of Americans currently are using them. Used appropriately under physician supervision, VLCD appear to be safe and effective for the short term. Additional research is needed to determine the long term implications of repeated use of VLCD and any long term benefits or adverse effects. Exercise produces little additional weight loss above that seen with calorie restriction, but is thought to be a critical component of long term weight maintenance strategies. There is increasing interest and research on the benefits of strength training as well as aerobic exercise for obesity. Although carefully controlled research programs have shown that drug treatment of obesity produces weight loss, there are few long term studies of drugs for obesity. Stringent state and Federal Nutrition Reviews, Vol. 50,No. 11
regulations prevent use of these drugs for longer than three months by physicians, and this precludes any role in long term treatment of obesity. Reevaluation of drugs for obesity is necessary in view of recent data suggesting long term efficacy in some people. The short term benefits of weight reduction in obesity are clear. There is rapid improvement in many of the complications of obesity such as glucose intolerance and insulin resistance, hypertension, hyperlipidemia, and sleep apnea. Conversely, prevention of weight gain can prevent or delay the onset of these complications. Short term adverse effects of weight loss are mainly confined to the symptoms seen with VLCD and fasting, although there are suggestions of a temporary increase in gallbladder disease with slow as well as rapid weight loss. Improvements in psychosocial factors are seen in the short term, and may be particularly gratifying for the obese person. The long term benefits of weight reduction are less clear because there have been so few adequate studies. The early fears that weight cycling would lead to rebound weight gain and changes in body composition and metabolic status have been quieted, but there are still concerns about long term effects. Data from several epidemiological studies
Nutrition Reviews, Vol. 50, No. 11
presented at the Conference appeared to show that weight change is associated with increased mortality. However, these studies did not take into account the reasons for the weight loss, and more recent studies suggest that volitional weight loss is associated with a lower morbidity and mortality. The Expert Panel called strongly for additional long term, prospective studies of weight reduction in obesity. Discussion from representatives of the NIH and from Congress suggest that the American public and its institutions are finally recognizing obesity as a disease and a major public health problem, and that obesity will be an area of research concern in the future. 1. Summary Statement, NIH Technology Assessment Conference: Methods for voluntary weight loss and control. Ann Intern Med 1992;116:942-9
2. Kuczmarski RJ. Prevalence of overweight and weight gain in the United States. Am J Clin Nutr 1992;55:4958-502s 3. Wadden TA, Sternberg JA, Letizia KA, Stunkard AJ, Foster GD. Treatment of obesity by very low calorie diet, behavior therapy, and their combination: a five year prospective. Int J Obesity 1989;13(Suppl 2) :39-46
339
November 1992: 338-345
Editorial Treatment of 0besity Richard L. Atkinson, M.D. In March, 1992, an NIH Technology Assessment Conference was held in Bethesda, Maryland, on the topic of “Methods for Voluntary Weight Loss and Control.” During this Conference, a series of questions was addressed.’ Some of these questions were: 1. How often and in what ways do Americans try to lose weight? 2. How successful are various methods for weight loss and control? What are the attributes of and barriers to successful weight loss methods/ approaches? 3. What are the short- and long-term benefits and adverse effects of weight loss? It is apparent that a large percentage of Americans are attempting to lose weight by a variety of methods. Obesity is a major public health problem in America, since 25 to 34% of adult Americans fulfill the criteria for obesity.2 Obesity is associated with numerous health problems, including diabetes mellitus, hypertension, hyperlipidemia, atherosclerotic disease, sleep apnea, gallbladder disease, and some types of cancer. Federal surveys have shown that from 33 to 40% of adult women and from 20 to 24% of adult men are currently trying to lose weight. Most obese individuals have attempted weight loss on several occasions, and a large industry has appeared to assist them. Commercial weight reduction programs and many community hospital programs have developed in recent years and estimates range as high as 30 to 40 billion dollars per year spent on weight reduction. With this massive effort, abuses occur, and 14% of female students admit to using self-induced vomiting in an attempt to lose weight.
Dr. Atkinson is at the Veterans Affairs Medical Center, Department of Internal Medicine, Eastern Virginia Medical School, Hampton, VA 23667.
338
Self-imposed diets and exercise are the most frequently used methods for weight control, but vitamins, diet supplements, and obesity medications are used by substantial numbers of people. The combination of diet, exercise, and behavior modification of lifestyle and eating habits is the approach recommended by most health professionals in the field. Unfortunately, this approach to weight control is difficult for most people to follow for the long term, and weight regain is frequent. Wadden et aL3 has shown that if no other treatment is given, less than 5% of individuals maintain weight loss for five years after completion of a comprehensive weight reduction program. The low success rate in people who are treated in university weight control programs may not be representative of the general population, as the proportion who have been unable to lose weight on their own is increased. The Expert Panel at the Technology Assessment Conference noted the paucity of long term studies, and recommended more research in the general population as well as in selected populations to identify the factors associated with success. Very low calorie diets (VLCD) for obesity are somewhat controversial, but since VLCD are part of many commercial weight reduction programs, millions of Americans currently are using them. Used appropriately under physician supervision, VLCD appear to be safe and effective for the short term. Additional research is needed to determine the long term implications of repeated use of VLCD and any long term benefits or adverse effects. Exercise produces little additional weight loss above that seen with calorie restriction, but is thought to be a critical component of long term weight maintenance strategies. There is increasing interest and research on the benefits of strength training as well as aerobic exercise for obesity. Although carefully controlled research programs have shown that drug treatment of obesity produces weight loss, there are few long term studies of drugs for obesity. Stringent state and Federal Nutrition Reviews, Vol. 50,No. 11
regulations prevent use of these drugs for longer than three months by physicians, and this precludes any role in long term treatment of obesity. Reevaluation of drugs for obesity is necessary in view of recent data suggesting long term efficacy in some people. The short term benefits of weight reduction in obesity are clear. There is rapid improvement in many of the complications of obesity such as glucose intolerance and insulin resistance, hypertension, hyperlipidemia, and sleep apnea. Conversely, prevention of weight gain can prevent or delay the onset of these complications. Short term adverse effects of weight loss are mainly confined to the symptoms seen with VLCD and fasting, although there are suggestions of a temporary increase in gallbladder disease with slow as well as rapid weight loss. Improvements in psychosocial factors are seen in the short term, and may be particularly gratifying for the obese person. The long term benefits of weight reduction are less clear because there have been so few adequate studies. The early fears that weight cycling would lead to rebound weight gain and changes in body composition and metabolic status have been quieted, but there are still concerns about long term effects. Data from several epidemiological studies
Nutrition Reviews, Vol. 50, No. 11
presented at the Conference appeared to show that weight change is associated with increased mortality. However, these studies did not take into account the reasons for the weight loss, and more recent studies suggest that volitional weight loss is associated with a lower morbidity and mortality. The Expert Panel called strongly for additional long term, prospective studies of weight reduction in obesity. Discussion from representatives of the NIH and from Congress suggest that the American public and its institutions are finally recognizing obesity as a disease and a major public health problem, and that obesity will be an area of research concern in the future. 1. Summary Statement, NIH Technology Assessment Conference: Methods for voluntary weight loss and control. Ann Intern Med 1992;116:942-9
2. Kuczmarski RJ. Prevalence of overweight and weight gain in the United States. Am J Clin Nutr 1992;55:4958-502s 3. Wadden TA, Sternberg JA, Letizia KA, Stunkard AJ, Foster GD. Treatment of obesity by very low calorie diet, behavior therapy, and their combination: a five year prospective. Int J Obesity 1989;13(Suppl 2) :39-46
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