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FEATURE ARTICLE

Treatment of Obesity: An Overview

Anthony N. Fabricatore, PhD, and Thomas A. Wadden, PhD

o be in the United lifestyle-treated patients was ~7 kg (at Obesity (NAASO) produced the Practi- States is to be a member of the month 6), which declined to ~4 kg (at cal Guide to the Identification, Evalua- majority. Recent data indicate that year 4). As shown in Figure 1, participa- tion, and Treatment of Overweight and T 8 fully 64% of American adults are either tion in the lifestyle intervention reduced Obesity in Adults. The NHLBI/NAASO overweight ( [BMI] = the risk of developing type 2 by guide contains an algorithm for selecting 25.0Ð29.9 kg/m2) or obese (BMI ≥30 58% compared with placebo and by appropriate treatments for overweight kg/m2).1 These figures represent a sharp 39% compared with metformin. The pre- and obese individuals based on BMI and increase over the value of 55% in 19942 ventive effect of lifestyle intervention estimated risk. The present arti- and reflect a doubling in the rate of obe- held for members of both sexes and all cle provides an overview of the treat- sity since 1980 (i.e., from 15 to 30%).1 racial and ethnic groups. ment algorithm (Table 1) and briefly The World Organization has The DPP clearly showed that weight reviews the empirical literature for each labeled obesity a global epidemic3; loss and increased can level of treatment. issues indeed, a recent report estimated that 1 prevent the development of type 2 dia- specific to patients with diabetes are then billion people worldwide are overweight betes.7 A follow-up trial, Action for discussed, as are suggestions to reduce and 300 million are obese.4 In the United Health in Diabetes (i.e., Look AHEAD), the prevalence of obesity. States, obesity has been estimated to is now investigating whether modest cost approximately $99 billion a year, weight loss (≥7%) and increased physi- TREATMENT OF OBESITY principally through its association with cal activity (≥175 minutes per week) will , , reduce the incidence of fatal and nonfa- Lifestyle Modification and some types of .5 tal attack and in overweight The NHLBI/NAASO algorithm8 recom- There is good news amidst these individuals who already have type 2 dia- mends that individuals with a BMI ≥30 alarming statistics—small weight losses betes. This is the first randomized, kg/m2, as well as those with a BMI of can have large health benefits. Recent prospective trial to examine this issue. 25.0Ð29.9 kg/m2 plus two or more dis- studies have shown that a 5Ð10% reduc- There are numerous options for the ease risk factors, attempt to lose weight tion in initial weight is associated with treatment of obesity. A collaboration by adhering to a program of , exer- significant improvements in blood pres- between the National Heart, Lung, and cise, and behavior therapy. These three sure, cholesterol levels, and glycemic Blood Institute (NHLBI) and the North components are frequently referred to as control.6 American Association for the Study of lifestyle modification and are the corner- Results of the Diabetes Prevention stone of obesity treatment. Lifestyle Program (DPP)7 have provided the most modification is distinct from . IN BRIEF definitive evidence to date of the health Dieting implies adhering to a particular benefits of modest weight loss. More Obesity and type 2 diabetes common- regimen for a discrete period of time, than 3,200 overweight individuals with ly co-occur. Weight loss is associated whereas lifestyle modification involves impaired glucose tolerance (IGT) were with significant health benefits, implementing dietary and behavioral randomly assigned to one of three condi- including improved glycemic control changes that can be sustained indefinite- tions: 1) placebo; 2) metformin (Glu- and reduced blood pressure. This arti- ly to promote health. cophage, 850 mg/day); or 3) a lifestyle cle reviews approaches to the treat- intervention designed to induce a loss of ment of obesity, considers special Dietary interventions 7% of initial weight and to increase issues relevant to obese patients with Dietary interventions for obesity are ≥ physical activity to 150 minutes per type 2 diabetes, and presents sugges- designed to create a negative energy bal- week. Participants were treated for up to tions for the prevention of obesity. ance (i.e., calories ingested < calories 4 years. The maximum weight loss in expended) by reducing daily energy

CLINICAL DIABETES • Volume 21, Number 2, 2003 67 FEATURE ARTICLE

labels, measuring portion sizes, and recording their intake as soon as possible after eating. The more self- monitoring records patients complete each week, the more weight they lose.11 There are several options for facili- tating adherence to an LCD, including the use of structured meal plans. Wing et al.12 randomized women to one of four weight loss groups, with varying levels of structure: 1) behavior therapy alone with a self-selected diet of con- ventional ; 2) behavior therapy plus a prescribed menu for five break- fasts and five dinners per week; 3) behavior therapy plus the prescribed foods at a decreased price; and 4) Figure 1. Cumulative incidence of diabetes for participants in the Diabetes behavior therapy plus the prescribed Prevention Program. The diagnosis of diabetes was based on the criteria of the foods at no cost. Participants in groups American Diabetes Association. The incidence of diabetes differed significantly 2, 3, and 4 lost significantly more among the three groups (P ≤ 0.001 for each comparison). Reprinted with permis- weight after 6 months of treatment and sion from Ref. 7. maintained greater losses at 18 months’ intake below energy requirements. NAASO guide recommends LCDs of follow-up than did those in group 1. Energy requirements vary by sex, 1,000Ð1,200 kcal/day for most over- This finding suggests that the provision weight, and level of physical activity weight women and 1,200Ð1,600 of structure induces greater weight loss such that men, heavier individuals, and kcal/day for overweight men (and for than does behavior therapy alone with a more active individuals have greater women who regularly or weigh self-selected diet. There were no differ- energy needs.9 Uniformly, however, ≥75 kg).8 The recommended macronutri- ences in weight loss among groups 2, 3, greater energy deficits result in greater ent composition of these diets is shown and 4 at the end of treatment or at fol- weight losses. Two levels of reducing in Table 2. low-up. This finding indicates that pro- diets are described below. Careful self-monitoring of calorie viding detailed menus is sufficient to Low-calorie diets (LCDs). An LCD intake is crucial to the success of LCDs. structure patients’ dietary adherence. is designed to create an energy deficit of Obese individuals underestimate their Jeffery et al.13 have reported similar 500Ð1,000 kcal/day and induce a weight intake by ~30Ð50%.10 Thus, patients findings concerning the benefits of loss of 0.5Ð1 kg/week. The NHLBI/ must be instructed in reading food structured meal plans.

Table 1. A Guide to Selecting Treatment

Treatment BMI Category (kg/m2) 25Ð26.9 27Ð29.9 30Ð34.9 35Ð39.9 ≥40

Diet, physical activity, With With and behavior therapy comorbidities comorbidities

Pharmacotherapy With comorbidities

Surgery With comorbidities

Note. Prevention of with lifestyle therapy is indicated in any patient with a BMI ≥25 kg/m2, even without comorbidities, whereas weight loss is not necessarily recommended for those with a BMI of 25Ð29.9 kg/m2 or a high circumference unless they have two or more comorbidities. Combined therapy with a low-calorie diet, increased physical activity, and behavior therapy provide the most successful intervention for weight loss and weight maintenance. Consider pharmacotherapy only if a patient has not lost 1 lb/week after 6 months of com- bined lifestyle therapy. The represents the use of indicated treatment regardless of comorbidities. Reprinted from Ref. 8.

68 Volume 21, Number 2, 2003 • CLINICAL DIABETES FEATURE ARTICLE

Table 2. Low-Calorie Step I Diet in the absence of caloric restriction. To illustrate: a program of 45Ð60 Nutrient Recommended Intake minutes 4 days a week will create a deficit of approximately 1,000 kcal over Calories ~500Ð1,000 kcal/day reduction from usual intake the course of a week, with the resulting Total 30% or less of total calories loss of 0.15 kg. By contrast, LCDs are Saturated fatty acids 8Ð10% of total calories designed to induce weekly deficits of Monounsaturated fatty acids Up to 15% of total calories 3,500Ð7,000 kcal, with weight losses of 0.5Ð1 kg per week. Polyunsaturated fatty acids Up to 10% of total calories The greatest benefit of physical Cholesterol <300 mg/day activity is in facilitating the maintenance Protein ~15% of total calories of weight loss.23 Case studies have Carbohydrate 55% or more of total calories shown that people who exercise regular- ly are more successful in maintaining Sodium chloride No more than 100 mmol/day (~2.4 g of sodium or weight losses than are those who do not ~6 g of sodium chloride exercise.24,25 Additional evidence comes Calcium 1,000Ð5,000 mg/day from randomized trials. Participants who Fiber 20Ð30 g/day receive diet plus exercise maintain greater weight losses 1 year after treat- Reprinted from Ref. 8. ment than do those who receive diet alone, although the differences are not Liquid meal replacements provide patients with a BMI ≥30 kg/m2 who have always statistically significant.26 another method of facilitating adherence failed to lose weight using an LCD.17 Physical activity can be divided into to an LCD. Ditschuneit et al.14 showed VLCDs provide 200Ð800 kcal/day, with two types: programmed and lifestyle. that patients who replaced two meals a large amounts of protein (70Ð100 g/day) Programmed activity is typically day with a shake lost 8% of initial to preserve . Liquid for- planned, aerobic, and completed in a sin- weight during 3 months of treatment, mula diets are supplemented with vita- gle bout (e.g., walking, biking, aerobics whereas those who were prescribed the mins and minerals that also must be tak- classes). Lifestyle activity involves same number of calories (i.e., 1,200Ð en if a diet of lean meat, fish, or fowl is increasing energy expenditure through- 1,500 kcal/day) but consumed a self- consumed. VLCDs should only be used out the day by methods such as using selected diet of conventional foods lost under appropriate medical supervision. stairs rather than escalators or choosing a only 1.5% of initial weight. Ashley et These diets produce weight losses of distant parking spot. Andersen et al.27 al.15 similarly found that a liquid meal 15Ð25% in 8Ð16 weeks,17 but are not as found that the two types of activity, replacement produced significantly larg- widely used today as a decade ago. This when combined with diet, both produced er losses than a conventional diet with can be attributed to their cost (i.e., a loss of ~8 kg in 16 weeks. There was, the same calorie goal. approximately $3,000 for a 6-month pro- however, a trend (P = 0.06) for lifestyle Meal replacements may also facili- gram) and to findings of significant activity to be associated with less weight tate the maintenance of weight loss. weight regain. Several randomized trials regain than was programmed activity 1 Patients in the Ditschuneit study who found VLCDs to be no more effective year after treatment (0.08 vs. 1.6 kg, continued to replace one meal and one than LCDs 1 year after treatment.18Ð21 respectively). Given these favorable find- snack a day with shakes or snack bars These findings led an expert panel con- ings, lifestyle activity would appear to be maintained an 8% weight loss at 51 vened by NHLBI not to recommend the ideal for obese individuals who say they months.14 In another study,16 men who use of VLCDs.22 hate to exercise. were given products for 5 years achieved and maintained a Physical activity Behavior therapy loss of 5.8 kg at the end of that time, Physical activity is the second compo- Behavior therapy provides patients a set while women achieved and maintained a nent of lifestyle modification. The bene- of principles and techniques to facilitate loss of 4.2 kg. Male and female controls fits of physical activity include inducing their adherence to the diet and activity in this nonrandomized study gained an negative energy balance (by increasing goals described above. The behavioral average of 6.7 and 6.5 kg, respectively, calorie expenditure), sparing fat-free approach has been described at length in during the same 5-year period. mass during weight loss, and improving other publications to which readers are Very-low-calorie diets (VLCDs). cardiovascular fitness. Physical activity, referred.28,29 Common techniques VLCDs are typically recommended for however, produces minimal weight loss include self-monitoring (of food and

CLINICAL DIABETES • Volume 21, Number 2, 2003 69 FEATURE ARTICLE

activity), stimulus control, slowing eat- as monoamine oxidase inhibitors or gastroplasty (VBG) and gastric bypass ing, cognitive restructuring, problem selective serotonin reuptake inhibitors.38 (GB). Both entail isolating a small (15- solving, and relapse prevention. Unfortunately, obese individuals are at to 30-ml) pouch of stomach with a line Behavior therapy typically is deliv- increased risk for conditions that render of staples, thereby drastically limiting ered to groups of 10Ð20 participants in the use of inappropriate. food intake. In VBG, the pouch empties 60- to 90-minute sessions for 20Ð26 is a gastric lipase inhibitor into the remaining stomach, where the weeks. Several reviews have shown that that blocks the absorption of about one- digestive process continues as normal. patients lose 9Ð10% of their starting third of the fat contained in a meal,39 GB, however, not only restricts food weight28Ð30 but regain approximately leading to the loss of about 150Ð180 intake, but also reduces absorption by one-third of the lost weight in the year kcal/day. Patients are negatively rein- bypassing the remaining stomach and following treatment.31 Perri et al.32,33 forced to eat a low-fat diet because the 45Ð150 cm of small intestine.43 have shown that continued patient- consumption of more than 20 g of fat per produces average provider contact following treatment, in meal, or 70 g of fat per day, can induce reductions of 25% (VBG) to 30% (GB) person or by mail, significantly improves adverse gastrointestinal events that of initial weight44 and significant the maintenance of weight loss. Long- include oily stools, flatus with discharge, improvements in , , term treatment recognizes that obesity is and fecal urgency. In randomized trials, apnea, and diabetes.45 Improve- a similar to hyperten- participants who received placebo plus ments in mood have also been reported, sion or diabetes. diet lost 6% of their weight in 1 year, but they appear to wane with time.46 compared with 10% for those treated by Randomized trials have shown that Pharmacological Interventions orlistat plus diet.39,40 GB is associated with significantly better As BMI or disease risk increase, more The greatest benefit of pharma- maintenance of weight loss than is intensive options are available for the cotherapy may reside in facilitating the VBG.47 This has been attributed to the treatment of obesity. Pharmacotherapy is maintenance, rather than the induction, “dumping syndrome” associated with recommended for individuals with a of weight loss. Two-year studies of sibu- GB, in which patients experience nau- BMI ≥30 kg/m2 or with a BMI ≥27 tramine36,41 and orlistat39,40 showed that sea, cramping, and other gastrointestinal kg/m2 in the presence of two or more participants who remained on medica- symptoms after eating high-/high- obesity-related comorbidities (e.g., coro- tion at the end of this time maintained fat foods. Patients learn to avoid these nary heart disease, type 2 diabetes, or losses nearly twice as great as those of foods, whereas VBG patients can contin- ) and who cannot lose participants who received placebo. They ue to eat them and thus may regain weight satisfactorily with more conser- also maintained significantly greater weight. Patients treated by GB main- vative approaches.22 Two — improvements in lipid values.36,39Ð41 tained a loss of 50% of excess weight as sibutramine (Meridia) and orlistat These findings suggest that weight loss long as 14 years postoperatively.48 (Xenical)—are approved by the Food medications should be used long term in These findings undoubtedly have and Drug Administration for the induc- the same manner as agents for hyperten- contributed to the recent surge in popu- tion and maintenance of weight loss.34 sion, diabetes, or . larity of bariatric surgery, as has the abil- Sibutramine is a combined sero- There are several barriers, however, to ity to perform the procedures laparo- tonin-norepinephrine reuptake inhibitor the long-term use of weight loss medica- scopically. reduces hospital that is associated with reports of tions, including findings that most stay time, as well as operative morbidity increased satiation (i.e., fullness). When patients must pay out-of-pocket for anti- and mortality.49 used with an LCD, sibutramine (10Ð15 obesity agents.42 costs typi- The screening process for bariatric mg/day) produced a significantly greater cally exceed $100 per month. surgery is rigorous. Candidates must meet loss of initial weight (7%) than an LCD weight and medical requirements and also plus placebo (2%) over the course of 1 Surgical Interventions should undergo a comprehensive multi- year.35 Reductions of 10Ð15% have been Bariatric surgery, the most intensive disciplinary assessment to identify behav- observed in studies that combined sibu- treatment for obesity, is appropriate only ioral contraindications to surgery (as tramine with intensive lifestyle modifica- for those individuals with a BMI ≥40 described by Wadden et al.50) Pre-surgical tion.36,37 However, sibutramine is not rec- kg/m2 or BMI ≥35 kg/m2 in the presence counseling is appropriate to ensure that ommended for patients with of comorbidities.22 Typically, people patients have realistic weight loss expec- uncontrolled hypertension or a history of who seek bariatric surgery have exhaust- tations and understand the postoperative , arrhythmias, ed the more conservative weight loss dietary requirements. In addition, candi- congestive , or stroke. It is options without satisfactory results. dates should be fully informed of the risks also not recommended in combination The two most common surgical pro- of bariatric surgery, which include an with certain agents, such cedures for obesity are vertical banded operative of ~1.5%.48,51

70 Volume 21, Number 2, 2003 • CLINICAL DIABETES FEATURE ARTICLE

SPECIAL CONSIDERATIONS FOR and IGT for up to 14 years after under- 5Wolf AM, Colditz GA: Current estimates of the economic cost of obesity in the United States. PATIENTS WITH DIABETES going and found Obes Res 6:97Ð106, 1998 According to the American Diabetes that 82.9% of the patients with diabetes 6Blackburn GL: Effect of degree of weight Association (ADA),52 type 2 diabetes and 98.7% of the patients with IGT loss on health benefits. Obes Res 3:211SÐ216S, accounts for 90Ð95% of all cases of dia- maintained normal levels of blood glu- 1995 7 betes, and ~90% of patients with type 2 cose and hemoglobin A1c long term. Diabetes Prevention Program Research Group: Reduction in the incidence of type 2 dia- diabetes are overweight. Overweight betes with lifestyle intervention or metformin. N patients with IGT or diagnosed type 2 PREVENTION EFFORTS Engl J Med 346:393Ð403, 2002 diabetes can reap significant health ben- Obesity and type 2 diabetes are increas- 8National Institutes of Health/National Heart efits with modest weight reductions.6,7 ing in prevalence, not only among Lung and Blood Institute, North American Asso- ciation for the Study of Obesity: Practical Guide Even before they lose weight, patients adults, but also among children and ado- to the Identification, Evaluation, and Treatment may achieve significant short-term lescents in the United States.1,58 These of Overweight and Obesity in Adults. Bethesda, Md., National Institutes of Health, 2000 reductions in blood glucose as a result trends, in conjunction with obesity’s 9 53 Melanson K, Dwyer J: Popular diets for of adhering to a hypocaloric diet. medical, psychological, and economic treatment of overweight and obesity. In Hand- Patients treated with and sulfony- effects, highlight the need for interven- book of Obesity Treatment. Wadden TA, Stunkard AJ, Eds. New York, Guilford Press, 2002, p. lureas are at increased risk of hypo- tions and policy directives aimed at pre- 249Ð275 glycemia and must monitor their blood venting obesity. Efforts to remove soft 10Lichtman SW, Pisarka K, Berman ER, glucose regularly when attempting drinks from public schools have begun Pestone M, Dowling H, Offenbacher E, Weisel H, weight loss. in some cities. Additionally, Horgen and Heshka S, Matthews DE, Heymsfield SB: Dis- crepancy between self-reported and actual caloric Wing et al.21,54Ð56 have provided a Brownell59 have offered the following intake and exercise in obese subjects. N Engl J wealth of clinical and research findings public policy recommendations to Med 327:1893Ð1898, 1992 on the behavioral management of obese reduce the incidence of obesity: regulate 11Baker RC, Kirschenbaum DS: Self-monitor- ing may be necessary for successful weight con- individuals with type 2 diabetes. Health food advertising aimed at children, sub- trol. Behav Ther 24:377Ð394, 1993 providers are referred to this work for sidize the sale of healthy foods, tax 12Wing RR, Jeffery RW, Burton LR, Thorson practical suggestions. unhealthy foods, and provide resources C, Nissinoff K, Baxter JE: Food provisions vs. for increased physical activity. structured meal plans in the behavioral treatment of obesity. J Consult Clin Psychol 20:56Ð62, Liquid Meal Replacements and Obesity prevention promises to be a 1996 Diabetes formidable task, given that American 13Jeffery RW, Wing RR, Thornson C, Burton Yip et al.57 recently compared changes culture fosters a “toxic environment”59 in LR, Raether C, Harvey J, Mullen M: Strengthen- ing behavioral interventions for weight loss: a in weight and fasting glucose levels in which less energy is expended and calo- randomized trial of food provision and monetary obese individuals with type 2 diabetes rie-dense, inexpensive foods are both incentives. J Consult Clin Psychol 61:1038Ð1045, who consumed a diet of regular (sug- heavily advertised and readily available. 1993 ared) meal replacements, sugar-free The full efforts of clinicians, researchers, 14Ditschuneit HH, Flechtner-Mors M, John- son TD, Adler G: Metabolic and weight loss meal replacements, or an exchange diet and lawmakers, however, may pay large effects of long-term dietary intervention in obese plan based on ADA recommendations. dividends. If we fail to treat obesity as a subjects. Am J Clin Nutr 69:198Ð204, 1999 After 12 weeks of treatment, patients problem and implement 15Ashley JM, St Jeor ST, Schrage JP, Perumean-Chaney SE, Gilbertson MC, McCall using meal replacements (regardless of bold prevention and policy initiatives, NL, Bovee V: Weight control in the physician’s sugar content) lost more weight the incidence of obesity and its related office. Arch Intern Med 161:1599Ð1604, 2001 (6.4Ð6.7%) than those using the complications can only increase in the 16Rothacker DQ: Five-year self-management exchange diet plan (4.9%) and had sig- years to come. of weight using meal replacements: comparison with matched controls in rural Wisconsin. Nutri- nificantly lower fasting glucose levels. tion 16:344Ð348, 2002 REFERENCES These findings should reassure patients 17Wadden TA, Osei S: The treatment of obesi- who are concerned that popular liquid ty: an overview. In Handbook of Obesity Treat- 1Flegal KM, Carroll MD, Ogden CL, Johnson ment. Wadden TA, Stunkard AJ, Eds. New York, meal replacements may contain as many CL: Prevalence and trends in obesity among U.S. Guilford Press, 2002, p. 229Ð248 as 39 g of sugar per serving. The sugar adults, 1999Ð2000. JAMA 288:1723Ð1727, 2002 18Ryttig KR, Flaten H, Rossner S: Long-term does not appear to be a problem if 2Flegal KM, Carroll MD, Kuczmarski RJ, effects of a very low calorie diet (Nutrilett) in patients are in negative energy balance. Johnson CL: Overweight and obesity in the Unit- obesity treatment: a prospective, randomized ed States: prevalence and trends, 1960Ð1994. Int comparison between VLCD and a hypocaloric J Obes 22:39Ð47, 1998 diet + behavior modification and their combina- tion. Int J Obes 21:574Ð579, 1997 Bariatric Surgery and Diabetes 3World Health Organization: Obesity: Pre- For patients with extreme obesity, venting and Managing the Global Epidemic. 19Wadden TA, Foster GD, Letizia KA: One- Geneva, World Health Organization, 1998 year behavioral treatment of obesity: comparison bariatric surgery represents a potential of moderate and severe caloric restrictions and cure for type 2 diabetes. Pories et al.51 4World Health Organization: The world health the effects of weight maintenance therapy. J Con- report 2002 [online]. Available at sult Clin Psychol 62:165Ð171, 1994 followed patients with type 2 diabetes http://www.who.int/whr/2002/en/ [2002]

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20Wing RR, Marcus MD, Salata R, Miask- after weight loss: a randomized trial. Lancet Who would have thought it? An operation proves iewicz S, Blair EH: Effects of a very-low-calorie 356:2119Ð2125, 2000 to be the most effective therapy for adult-onset diet on long-term glycemic control in obese type diabetes mellitus. Ann Surg 222:339Ð352, 1995 37Wadden TA, Berkowitz RI, Sarwer DB, II diabetic subjects. Arch Intern Med 52 151:1334Ð1340, 1991 Prus-Wisniewski R, Steinberg C: Benefits of American Diabetes Association: Type 2 dia- lifestyle modification in the pharmacologic treat- betes [online]. Available at 21Wing RR, Blair E, Marcus MD, Epstein LH, ment of obesity: a randomized trial. Arch Intern http://www.diabetes.org [2002] Harvey J: Year-long weight loss treatment for Med 161:218Ð227, 2001 53Williams KV, Kelley DE, Mullen ML, Wing obese patients with type II diabetes: does inclu- 38 sion of intermittent very low calorie diet improve Abbott Laboratories: MERIDIA (sibu- RR: The effect of short periods of caloric restric- outcome? Am J Med 97:354Ð362, 1994 tramine hydrochloride manohydrate). Product tion on weight loss and glycemic control in type information. In Physician’s Desk Reference. 2 diabetes. Diabetes Care 21:2Ð8, 1998 22National Institutes of Health/National Heart Montvale, NJ, Thompson PDR, 2003, p. 475Ð480 54Wing RR, Epstein LH, Nowalk MP, Scott N, Lung and Blood Institute: Clinical guidelines on 39 the identification, evaluation, and treatment of Sjöstrom L, Rissanen A, Andersen T, Koeske R, Hagg S: Does self-monitoring of overweight and obesity in adults: the evidence Boldrin M, Golay A, Koppeschaar HPF, Krempf blood glucose levels improve dietary compliance report. Obes Res 6:51SÐ210S, 1998 M: Randomized placebo-controlled trial of orlis- for obese patients with type II diabetes? Am J tat for weight loss and prevention of weight Clin Med 81:830Ð836, 1986 23 Pronk NP, Wing RR: Physical activity and regain in obese patients. Lancet 352:167Ð172, 55 long-term maintenance of weight loss. Obes Res 1998 Wing RR, Koeske R, Epstein LH, Nowalk 2:587Ð599, 1994 MP, Gooding W, Becker D: Long-term effects of 40Davidson MH, Hauptman J, DiGiorlamo M, modest weight loss in type 2 diabetic patients. 24Kayman S, Bruvold W, Stern JS: Mainte- Foreyt JP, Halstead CH, Heber D, Heimburger Arch Intern Med 147:1749Ð1753, 1987

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29 Weight loss with vertical banded gastroplasty and Wilson GT, Brownell KD: Behavioral treat- Roux-Y gastric bypass with selective vs. random ACKNOWLEDGMENT ment for obesity. In Eating Disorders and Obesi- assignment. Am J Surg 157:93Ð102, 1989 ty. 2nd ed. Fairburn CG, Brownell KD, Eds. New York, Guilford Press, 2002, p. 524Ð533 45Kral JG: Surgical treatment of obesity. In Preparation of this article was supported,

30 Treatment of the Seriously Obese Patient. Wad- Wadden TA, Foster GD: Behavioral treat- den TA, VanItallie TB, Eds. New York, Guilford in part, by grant 1-U01-DK57135 from ment of obesity. Med Clin North Am 84:441Ð461, Press, 1992, p. 496Ð506 the National Institute of Diabetes and 2000 46 Digestive and Kidney . 31 Karlsson J, Sjöstrom L, Sullivan M: Wadden TA, Brownell KD, Foster GD: Obe- Swedish obese subjects (SOS): an intervention sity: responding to the global epidemic. J Consult study of obesity: two-year follow-up of health- Clin Psychol 70:510Ð525, 2002 related quality of life (HRQL) and eating behav- Anthony N. Fabricatore, PhD, is an 32Perri MG, Shapiro RM, Ludwig WW, Twen- ior after gastric surgery for severe obesity. Int J instructor of psychology, and Thomas A. Obes Relat Metab Disord 22:113Ð126, 1998 tyman CT, McAdoo WG: Maintenance strategies Wadden, PhD, is a professor of psychol- for the treatment of obesity: an evaluation of 47Livingston EH: Obesity and its surgical relapse prevention training and postreatment con- management. Am J Surg 184:103Ð113, 2002 ogy and director of the Weight and Eat- tact by telephone and mail. J Consult Clin Psy- ing Disorders Program in the Depart- chol 52:404Ð413, 1984 48Albrecht RJ, Pories WJ: Surgical interven- ment of at the University of 33Perri MG, McAllister DA, Gange JJ, Jordan tion for the severely obese. Bailliere’s Best Pract RC, McAdoo WG, Nezu AM: Effects of four Res Clin Endocrinol Metab 13:149Ð172, 1999 Pennsylvania School of Medicine in maintenance programs on the long-term manage- 49 ment of obesity. J Consult Clin Psychol Schauer PR, Ikramuddin S: Laparoscopic Philadelphia. 56:529Ð534, 1988 surgery for morbid obesity. Surg Clin North Am 81:1145Ð1180, 2001 34 Yanovski SZ, Yanovski JA: Obesity. N Engl 50 Note of disclosure: Dr. Wadden has J Med 346:591Ð602, 2002 Wadden TA, Sarwer DB, Womble LG, Fos- ter GD, McGuckin BG, Schimmel A: Psychoso- received research support and honoraria 35Lean MEJ: Sibutramine: a review of clinical cial aspects of obesity and obesity surgery. Surg for speaking engagements from Abbott Clin North Am 81:1001Ð1024, 2001 efficacy. Int J Obes 21:30SÐ36S, 1997 Laboratories and Roche Pharmaceuti- 51 36James WP, Astrup A, Finer N, Hilsted J, Pories WJ, Swanson MS, MacDonald KG, cals, which manufacture drugs for the Kopelman P, Rossner S, Saris WH, Van Gaal LF: Long SB, Morris PG, Brown BM, Barakat HA, Effect of sibutramine on weight maintenance deRamon RA, Israel G, Dolezal JM, Dohm L: treatment of obesity.

72 Volume 21, Number 2, 2003 • CLINICAL DIABETES