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weight reduction; intentional weight loss; excess weight reduction

The result of a conscious effort to lose weight or attenuate a tendency gain weight. Epidemiology: - low-income overweight or obese adults are less likely to be counseled to lose weight than adults with higher incomes [32] Physiology: - hormonal adaptations to weight loss may resist attempts to lose weight [15] Complications: - weight cycling (fluctuations) among middle-aged or older women is not associated with elevated all-cause mortality or cardiovascular mortality [7] Management: 1) goals of weight reduction - 5-10% weight reduction in 6 months is reasonable [43] - 25% weight reduction in 6 months is not [43] - this is a generalization not applicable to everyone 2) diet a) see weight loss diet b) reducing calories 500 kcal/day results in 1 pound weight loss/week c) weight reduction associated with vegetables, whole grains, fruits, nuts, yogurt [20] d) olive oil-rich Mediterranean diet better than low fat diet for weight reduction & reduction in waist circumference [34,35] e) weight gain associated with potatoes, sugar-sweetened beverages & meat [20] f) consistent reduction in daily calories is the most effective & safest weight reduction strategy in to lose weight [9] g) lower intake of dietary sugars is associated with lower weight & measures of body fat in people who do not intend to lose weight [22] h) fast-Food restaurant patrons underestimate calorie contents of meals, especially for larger meals & especially at Subway [23] i) calorie restriction in obese elderly results in loss of muscle mass thus is less preferable to exercise alone for weight reduction in obese elderly [25] - outcomes not considered j) gradual weight reduction no more effective than rapid weight reduction & rapid weight reduction is not associated with rapid regaining of weight [26] k) allowing choice of a diet, rather than prescribing one, does not improve weight loss [28] l) a low-fat plant-based diet reduces body weight & increases insulin sensitivity & postprandial metabolism in overweight patients [39] m) an anti-inflammatory diet [46] - dietary advanced glycation end-products & body weight decrease on a low-fat vegan diet [46] - weight reduction [5] 3) exercise (see aerobic exercise) 4) behavioral therapy [9] 5) drug therapy a) indications for drug therapy 1] BMI > 30 2] BMI > 27 + additional risk factors when diet & exercise alone are not enough 3] pharmacotherapy for weight reduction contraindicated during pregnancy [9] b) GLP-1 receptor agonists - liraglutide [9] (preferred agent) - semaglutide 2.4 mg/week subcutaneous c) serotonergic agents 1] selective serotonin reuptake inhibitor (SSRI) 2] serotonin agonist (triptan) - lorcaserin (do not use with SSRI) 3] short-term weight loss may occur 4] chronic use may lead to weight gain d) orlistat (Xenical) 1] FDA approved for long-term use 2] reduces weight by 10% over 1 year when combined with diet & exercise [2] 3] seems to be drug of choice [9] (MKSAP17) e) sibutramine (Meridia) 1] FDA approved for long-term use 2] reduces weight by 10% over 1 year when combined with diet & exercise [2] f) analeptics can suppress appetite for short-term 1] phentermine 2] diethylpropion g) bupropion (Wellbutrin) 1] short-term weight loss 2] no evidence it works long-term [2] 3] naltrexone-bupropion [9] h) zonisamide (Zonegran) {anticonvulsant} 1] may decrease appetite & reduce weight 6-10% 2] adverse effects may outweigh benefits [2,19] i) topiramate (Topamax) 1] may decrease appetite & reduce weight 6-10% 2] adverse effects may outweigh benefits [2] 3] phentermine/topiramate [13] j) comparison of different drug treatments [29] - patients with at least 5% weight loss at 1 year - placebo: 23% - phentermine/topiramate: 75% - injectable semaglutide best among glutides [40] - liraglutide: 63% - naltrexone-bupropion: 55% - lorcaserin: 49% - orlistat: 44% - excess weight loss over placebo at 1 year - phentermine/topiramate: 8.8 kg - liraglutide: 5.3 kg - naltrexone-bupropion: 5.0 kg - lorcaserin: 3.2 kg - orlistat: 2.6 kg - likelihood of discontinuing because of adverse events compared with placebo - highest with liraglutide (odds ratio, 2.95) - lowest with lorcaserin (OR, 1.34) [29] 6) dietary supplements generally NOT proven safe or effective [2] a) Metabolife b) Xanadrine c) Dexatrim Results e) products with ephedra or ephedrine-related compounds 1] bitter orange 2] country mallow 3] heart leaf 4] ma huang d) ephedra-free products often substitute a similar stimulant with a different name 7) even small weight reductions can reduce risk of: a) diabetes mellitus type 2 b) hypertension - 10 kg (22 lb) weight reduction can lower systolic blood pressure 5-20 mm Hg [9] c) heart disease 8) no evidence that weight reduction will improve mortality [25,42] 9) bariatric surgery may be indicated for morbidly obese 10) commercial weight reduction programs a) little evidence to suggest benefit [4] b) more effective than advice from primary care doctor [14] c) wearable device that tracks exercise & energy expenditure of little or no benefit [30] d) weight management programs effective in patients taking antidepressants &/or antipsychotics [37] 11) home-case component + monthly group meetings most effective strategy [5] 12) professional sports-linked programs may motivate men to lose weight [24] 13) adequate sleep is an important component of any weight reduction program [6,10,12] 14) without pharmaceutical aids, the best success comes when patients use computer or other technology-based tools to motivate themselves [16,21] 15) follow-up focuses on relapse prevention, self-monitoring, & social support may be of benefit - 3 group visits with a dietitian within 10 weeks - 8 phone calls within 40 weeks [33] 16) lower carbohydrate, higher fat intake, with stable protein & energy intake, results in higher energy expenditure during weight-loss maintenance [36] 17) intermittent fasting - of no benefit over standard meals [38] - may be of benefit at least in short term [41] - intermittent fasting (8-10 hours/day) as effective as calorie-restriction for weight reduction [45] Notes: - among commercial weight reduction programs including Weight Watchers, Jenny Craig, Nutrisystem, Health Management Resources (HMR), Medifast, OPTIFAST, Atkins, The Biggest Loser Club, eDiets, Lose It!, & SlimFast, only Jenny Craig & Weight Atchers able to achieve modest weight loss at 1 year (4.9% with Jenny Craig, 2.6% with Weight Watchers) relative to control group [27]

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weight loss

References

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