Interventions in Morbid Obesity

Abstracted from Innovations in Clinical Practice: A Source Book (Volume 20, 2002).

More than 50% of adults in the U.S are overweight or obese. The prevalence of overweight and obesity has risen tremendously since 1960. In the last decade the percentage of overweight or obese adults age 20 years or greater has increased to 54.9%. In addition, the number of overweight children has doubled in the last 20 years.

Obesity is now viewed, much like diabetes or hypertension, as a chronic disease. This multifactorial chronic disease has its roots in genetic, metabolic,physiological, social, behavioral, and cultural factors.Although we may inherit the tendency to develop obesity, the expression of obesity is affected by diet and exercise.

GOALS OF WEIGHT LOSS

Weight loss of 1-2 lbs per week is reasonable as a immediate goal. An intermediate, and potentially long-term, goal may be 10% weight loss from baseline. The NIH (1998) guidelines suggest a reasonable time line for a 10% reduction in weight should be six months. Once a desired weight is attained, a maintenance program must be instituted. It is well documented that weight is regained within a year once any treatment is stopped. Again, it is necessary to view overweight and obesity as a chronic condition that needs ongoing attention.

WEIGHT LOSS STRATEGIES

Diet: In any weight reduction plan a balanced deficit of 500 to 1,000 kcal/day is necessary. Reduction of total calories from fat to 30% or less is also necessary. Of course, many of the fat calories removed from the diet should be saturated fat. Reduction of saturated fat enhances lowering of the LDL-cholesterol. However, reducing fat calories alone will not promote weight loss. Similarly, replacing fat calories with carbohydrate calories will not lead to weight loss. Reduction of fat and carbohydrate calories will be necessary to produce a sufficient deficit for weight loss.

Exercise: While most weight loss occurs because of decreased caloric intake, physical activity remains an important factor in weight loss. However, the NIH (1998) Guidelines suggest that exercise will not lead to substantially greater weight loss over a six-month period. Additionally, specific kinds of excercise (e.g., muscle building activities) may limit weight loss or, actually, promote weight gain. However, increasing lean muscle mass is still beneficial because muscle requires more energy expenditure for use as fuel. The fuel source used can be stored fat, which promotes weight loss. Maintenance of physical exercise is helpful in preventing weight gain. An additional benefit of exercise is the reduction of cardiovascular and diabetes risk factors.

Behavior therapy: Specific, learning-theory based principles, such as reinforcement, self-monitoring (of both food intake and physical activity), stimulus control, contingency management, cognitive restructuring, stress management, and social support are very important in attaining weight loss and weight maintenance.

Combined Therapy: Combining the above three methods (low calorie diet, increased physical activity, and behavior therapy) provides the most success for weight loss and weight maintenance. This combination approach should be instituted and maintained for at least 6 months before pharmacotherapy is entertained (NIH Guidelines, 1998).

Gerald J. Strauss, Ph.D.
Staff Psychologist