Duke Internal Medicine Residency Curriculum
Evidence- Based Management of
Obesity in Primary Care
Natalie M. Bachir
Katie Twomley
Angela Coscio
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Learning Objectives
•
Identify the obese patient
•
PCP and patient should be clear that obesity is to be managed as a chronic
disease
•
Learn national guidelines on obesity therapy
•
Identify 3 serious medical problems associated with obesity
•
Advise patients on resources for smart dieting and refer to nutritionist for help
•
Know when to think about referring for surgery
•
Know the limitations of pharmacotherapy
•
Remember to think about referring to a psychologist
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Epidemiology of Obesity
• Rapidly growing epidemic
– In 2000, 64% of adults overweight, 30% obese
– Highest prevalence in minorities and poor
– Linear increase in obesity with decrease in income among
women
– Inverse relationship of education (y) and obesity
– Hispanic 70% > Black 65% > White 55%
• In 2003, 4 states have obesity rates >25%, 31 states
between 20-25%, and only 15 states have rates 15-20%
• No state has an obesity rate below 15% of the population
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CDC.gov
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Epidemiology — Prevalence 2003
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Pathogenesis — Genetic
•
No genes have been identified as contributing to common obesity in humans
•
Metabolic predictors of obesity: low metabolic rate, increased carbohydrate
oxidation, insulin resistance, low sympathetic activity
•
Under study are the beta-3 adrenergic receptor gene which modifies basal
energy expenditure and blood pressure, the ghrelin hormone involved in
hunger, cholecytokinin/enterstatin involved in satiety
•
Leptin gene related hyperphagia and insulin resistance has only been identified
in 2 consanguineous families
•
Obese persons do not have lower resting energy expenditure (BMR) or
metabolic responses to caloric intake
•
Obese persons underestimate their caloric intake and overestimate their
energy expenditure compared to normal wt
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Image: http://www.fewings.ca/polcan/040617Obesity.html
Bray, GA. Uptodate “Pathogenesis of Obesity”
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Pathogenesis — Environmental
• Obesity results from energy intake exceeding energy
expenditure
• Environmental predictors of obesity in the US: socioeconomic
status, ethnicity, education level, smoking status -The US as a
fat friendly environment
• Cultural/societal influence – US prevalence of obesity greater
than other western nations
• Length of residence in US predicts increasing obesity prevalence
for hispanic immigrants
– 10% at 0-4 y after immigration to 25% at >15 y
• Risk of obesity in adulthood increases with obesity in childhood,
especially obesity extending into adolescence
• Risk that a child will grow up to be an obese adult increases
with each parent that is obese
Kaplan,M Am J Prev Med 2004;27(4)323
Bray, GA. Uptodate “Pathogenesis of
Obesity”
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Morbidity of Obesity — Endocrine
• Metabolic Syndrome
– Prevalence of metabolic syndrome in the US approximately
30%
– Majority of metabolic syndrome is attributed to obesity
– Defined as 3 of 5 of the following: waist circumference > 35
in for women, 40 in for men; SBP > 135 or DBP > 85
(untreated); TGL > 150; HDL < 50 in women or < 40 in
men; FBG > 100
– Increases risk of type 2 DM by 7-10 times
– Increases the risk of CVD by 3-5 times
• Type 2 Diabetes
– Linear increase in risk of DM2 with BMI
– Risk of DM2 increases starting with BMI of 22
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AGA technical review of obesity
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Morbidity of Obesity — Cardiovascular
• Dyslipidemia
– Progressive increase in total cholesterol with increasing BMI in men
(NHANES III)
• Coronary artery disease
– Abdominal circumference independently associated with risk of CVD,
regardless of BMI
– Obesity recently listed as major risk factor for CHD
• Hypertension
– Abdominal circumference independently associated with
hypertension, regardless of BMI
– Greater than 2X prevalence of hypertension among obese
• Ischemic stroke
– Obese women had twice the number of ischemic strokes than
normal wt women in one epi study, a similar study in men showed
no statistical difference
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AGA technical review of obesity
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Morbidity — Pulmonary and Musculoskeletal
• Obstructive sleep apnea
– Increased risk of OSA with BMI>30 and neck circumference
> 17 inches
• Obesity hypoventilation syndrome
– Restrictive lung disease secondary to increased
weight/pressure on chest wall prohibiting expansion of lungs
• Osteoarthritis
– Obesity associated with increased prevalence of OA in both
weight-bearing and non-weight-bearing joints
– Weight loss improves symptoms of OA in the knees
• Gout
– Obesity associated with hyperuricemia and development of
gout
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AGA technical review of obesity
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Morbidity — Gastroenterology
• GERD
– Increased prevalence of reflux symptoms in obese persons, however
diet induced wt loss not shown to decrease symptoms
• Gallbladder disease
– Risk of symptomatic gallstones increases linearly with BMI
– Association is more remarkable in women than in men
• Pancreatitis
– Obesity associated with poor prognosis in pancreatitis
• NASH (non-alcoholic steatohepatitis)
– Over half of NASH attributable to obesity
– 10% of NASH results in cirrhosis
• Worsened prognosis in other liver disease (alcoholic and Hep C)
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AGA technical review of obesity
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Mortality
• Complicated due to use of multiple approximated
numbers: prevalence, relative risk, death rate
• Estimated to be as low as 112K or as high as >300K
depending on the estimates used and controlling for
confounders
• Risk of obesity-related mortality decreases with relative
risk near 1 at age 75 and above
• Calculations use prevalence of obesity and not duration of
obesity which may affect risk
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Flegal, K. Am J Public Health. 2004. 94(9): 1486
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Obesity in the Primary Care Setting
• Most people who lose weight and are dismissed from
clinical therapy will frequently regain the weight.
– Weight loss as an endpoint is an outdated health goal and
now the evidence shows that observation, monitoring, and
encouragement of patients who have lost weight should be
continued long-term, much like the management of a
chronic disease.
• In 1998 the NIH released a consensus statement of
evidence-based guidelines for management of the obese
patient, based on review of 394 RCTs 1/80 - 9/97.
• This has been endorsed by other groups such as the
American College of Preventive Medicine
• In 2003 the USPSTF released a consensus statement of
evidence-based guidelines
National Institutes of Health’s Expert Panel on the Identification, Evaluation,
and Treatment of Overweight and Obesity in Adults
Arch Intern Med Sept 1998;158:1855-1867
Am J Prev Med 2001;21(1):73-78.
summary
of USPSTF
evidence, McTigue
KM et al. Screening and
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interventions
for
obesity
in
adults:
summary
of
the evidence for the U.S.
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Preventive Services Task Force. Ann Intern Med 2003;139:933.
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PCP Barriers to Evaluation and Treatment Obesity
• Do you, your clinic, or your patient have any of these?
 Lack of payment by health-insurance and managed-care plans for
obesity-related treatment programs
 Lack of time for dedicated patient education and counseling on
weight loss and weight maintenance
 Lack of recognition of obesity as a chronic condition that is difficult
to treat, requires continuous and long-term management, and has
high relapse rates
 Insufficient data on the effectiveness of physician weight loss
counseling and skepticism about the success of any medical
treatment of obesity
 Lack of data on the long-term safety and efficacy of
pharmacotherapeutic agents for obesity
 Lack of patient interest or readiness for treatment
 Negative perceptions that obesity represents a lack of patient
discipline, self-control or will power rather than a chronic disease
 Inadequate training in the medical management of obesity
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Adapted from Table 7 in American Family Physician June 1, 2001;63(11):2185-2196
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Obesity Management in Primary Care
The Role of the PCP
•
•
•
•



Setting reasonable weight loss goals, selecting appropriate
weight loss programs, referring patients to ancillary personnel,
providing monitoring, support, encouragement.
Set an example by considering your own weight.
Understanding of causes of obesity and how obesity contributes
to disease
Heighten the patient’s motivation for weight loss, prepare
patient for treatment
Enumerate dangers which come with obesity
Describe strategy for clinically assisted weight loss. If the patient has
had previous unsuccessful attempts, describe how the new plan will be
different
Obesity is a chronic disease; the weight maintenance program will be
life-long
American Family Physician June 1, 2001;63(11):2185-2196
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Arch Intern Med Sept 1998;158:1855-1867
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Assessment — Degree of Overweight
NIH Approach: 2-Step Guideline of assessment and treatment
Accurate methods to assess total body fat include unavailable expensive
measures such as total body water, total body potassium, bioelectrical
impedance, dual-energy X-ray absorptiometry however there is no trial
data to indicate the best method. Similarly, to assess abdominal fat
content, MRI and CT are the most accurate but not practical.
Nonrandomized studies and clinical experience show that BMI is
significantly correlated with total body fat content.
= Kg/m2 or [lbs/in2]x703. BMI correlates with morbidity and mortality. Go
to http://www.nhlbisupport.com/bmi/ for BMI calculator.
Waist Circumference correlates with abdominal fat content. The presence
of excess fat in the abdomen is an independent predictor of risk factors
and morbidity, and is associated with increased risk for type 2 DM,
dyslipidemia, HTN, CVD.
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Arch Intern Med Sept 1998;158:1855-1867
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Assessment — Degree of Overweight
This chart indicates disease relative risk, relative to normal
weight and waist circumference. This will determine the
need to institute weight loss therapy in your patient.
Class
BMI (kg/m2)
Men 102 cm,
women 88 cm
Men >102 cm,
women >88 cm
Normal
18.5 - 24.9
…
…
Overweight
25-29.9
Increased
High
Obesity Class I
30-34.9
High
Very High
Obesity Class II
35-39.9
Very High
Very High
Obesity Class III
40
Extremely High Extremely High
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Assessment — Risk Status
Now to determine absolute risk, which is a summation of
risk factors. The following indicates increased risk for
disease complications and mortality, which again stresses
the need for weight loss reduction.
– Disease conditions.
• CAD, other atherosclerotic diseases, type 2 diabetes, sleep
apnea
• Gynecological abnormalities, OA, gallstones/GB complications,
stress incontinence
– Other risk factors.
• Physical inactivity, TGs >200mg/dL
• Cardiovascular risk factors. Cigarettes, HTN, LDL>160, HDL<35,
fasting glucose>110-125, family hx, age
– Remember to use the ATP III and JNC VII guidelines in assessment
and treatment of cholesterol and blood pressure
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Assessment — Patient Motivation
The patient needs to be ready to lose weight
Reasons and motivation for weight reduction
History of successful/unsuccessful weight loss attempts
Support of family, friends, worksite
Attitude towards physical activity, capacity to engage in physical activity
Time available for weight loss intervention, Financial considerations
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Assessment — Patient Motivation
Patients need to understand that losing weight is as medically
necessary as their prescription medications, and losing weight, if
done correctly, comes without side effects.
There has been a recent urging in all fields that counseling patients
in lifestyle changes should be given as much weight as knowing
which medication to prescribe when -- for example, at recent
meetings for the American Society for Hypertension and
American College of Sports Medicine.
http://www.surgeongeneral.gov/topics/obesity/calltoaction/1_2.htm
“Many Overweight Arthritis Patients Aren’t Told to Lose
Weight, Exercise” and “Urge Hyptertensives to Change
Habits,” Internal Medicine News Aug 1 2005;38(15) p.9
and p.55
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Image: http://www.medicineau.net.au/clinical/obesity/obesit1209.html
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Treatment Management — Weight Loss Goals
The initial goal is to reduce body weight by 10% from baseline in 6
months ;after this, further weight loss can be attempted.
Remember, the cornerstone of obesity therapy is to eat fewer calories than are
expended in order that endogenous fat stores will be consumed as fuel.
BMI (kg/m2)
25-29.9
30-34.9 35-39.9
40
Class
Overweight*
Class I
Class II
Class III
Energy Deficit (kcal/d)
500
500
500-1000
500-1000
Weight loss per week
(lb;kg)
1; 0.45
1; 0.45
1-2;
0.45-0.90
1-2;
0.45-0.90
*Weight loss recommendations in this group apply if the patient also has 2 or
more cardiovascular risk factors.
AGA technical review on obesity. Gastroenterology
2002; 123:882.
Arch Intern Med Sept
1998;158:1855-1867
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Treatment Management — Strategy
• After a 10% weight loss reduction at 6 months, if more weight
loss is needed, additional attempt at weight reduction. Or, a
weight maintenance program becomes a priority.
• If patients are unable to achieve weight loss, either a new
strategy needs to be pursued, or prevention of further weight
gain becomes a new goal.
• Strategy for Weight Loss and Weight Maintenance:
–
–
–
–
–
Dietary Therapy.
Physical Activity
Behavior Therapy
Pharmacotherapy for BMI >30 or >27 w/comorbidities
22 RCTs contain strong evidence that multimodal strategies for
weight loss work best
• Surgery for BMI>40 or BMI>35 w/comorbidities when medical
efforts have failed at 6 and 12 month checks
Arch Intern Med Sept 1998;158:1855-1867
USPSTF Guidelines: Screening for obesity in adults:
Recommendations and rationale (www.guideline.gov)
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Which diet to recommend?
48 RCTs reviewed by the expert panel: controlled energy/low
calorie, very controlled energy/very low calorie, vegetarian,
AHA, NCEP’s Step I w/energy intake restriction, other low-fat
regimen
Recommendations:
Controlled energy diet with fat reduction
• c/w NCEP Step I or Step II
– 500-1000 kcal/d energy deficit
– Total fat 30% or less of total energy
– Reduce saturated fat to reduce LDL-C
 Refer patients to AHA website and nutritionist for complete diet
plan
AHA Dietary Guidelines: revision 2000: a statement for healthcare professionals
•
from the Nutrition Committee of the American Heart Association.
Circulation. 2000;102:2284-2299.
American Institute for Cancer Research. Food, Nutrition and the Prevention of
Cancer: A Global Perspective. Washington, DC: World Cancer Research
Fund/American Institute for Cancer Research; 1997.
Executive Summary of the Third Report of the National Cholesterol Education
Program Expert Panel on Detection, Evaluation, and Treatment of High
Blood Pressure (ATP III) JAMA. 2001;285:2486-2497.
Curriculum
DHTS
Technology Education
Lowe MR etand
al. Obes
Res. 1999;7:51-59.
Weight watchers in based in sound medical dietary advice
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The High-Protein, High-Fat, Low-Carbohydrate Diet
•
The premise is that a metabolic ketosis is induced
resulting in quick weight loss. How?
– Most weight loss occurs in the first few weeks
– Diuretic effect due to -- very low carbohydrate
intake which influences sodium and water loss,
glycogen depletion, and ketosis
– Loss of appetite is associated with ketosis
– If 30% kcal from protein, negative energy balance
due to restriction in type/amount foods eaten
–  Efficacy and safety long term still not yet proven.
A popular premise of these diets is that excess
carbohydrates results in elevated insulin, which
promotes storage of body fat. However, protein
intake also stimulates insulin secretion.
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Circulation. 2001;104:1869-1874.
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The Data on Low-Carb, High-fat, High-Protein Diets
• Conflicting data regarding weight loss and influence on cardiac
risk factors in comparison to low-fat diet
– Some trials show difference in weight loss, some don’t
– Some trials show the high protein diet will increase HDL, decrease
TGs but increase LDL, which is of unclear benefit
– Low-carb diet is supplemented w/MVI, fish oil which may have effect
•  Sustained ADHERENCE to diet, rather than diet TYPE, found
to dictate weight loss and CV risk reduction
– Some trials show low-carb diet less sustainable, some show low-fat
diet less sustainable. One trial showed Weight Watchers had best
adherence
• Trial problems: diets used are not all uniform, primary
outcomes are reported as absolute amount rather than
percentage of weight lost, longest trial to date has a follow-up
JAMA, Jan 5 2005;293(1)
of one year.
Ann Intern Med 2004;140:769-777
N Engl J Med 2003;348:2074-2081.
N Engl J Med 2003;348:2082-2090
J Clin Endocrinol Metab. 2003;88:1617-1623
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Ann Intern Med
2004;140(10):778-785
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Calories
Here are the number of calories women and men need each day. The
obese person gets far more than these each day, due to overeating in
combination with a sedentary lifestyle.
Age
19-30
31-50
51+
Women
2000
1800
1600
Men
2400-3000
2200
2000
Taken from:
http://www.wegmans.com/eatwelllivewell/weightManagement/020105.a
sp
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The Medically Sound Diet
• For the protein diet:
– Total protein intake should not be excessive and be
proportional to carbohydrate and fat intake
– Carbohydrates should not be omitted or severely restricted
– Protein foods should not contribute excess total fat, saturated
fat, or cholesterol
– Should be safe long term by providing adequate nutrients and
comply with guidelines to prevent increase in disease risk.
– Protein 50-100g/day, 15% of kcal/day
– Carbohydrate at least 100g/day, 55% of kcal/day
– Fat 30% of kcal/day
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American Family Physician June 1, 2001;63(11):2185-2196
Circulation. 2001;104:1869-1874.
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• Potential Complications of Weight Loss:
–
–
–
–
–
Excessive loss of lean body mass
Dehydration
Electrolyte imbalance
Gallbladder disease
Psychological distress due to conflicts w/loved ones,
etc
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Physical Activity
– Prevention of weight regain, moderately contributes to
weight loss, increases cardiorespiratory fitness
– Reduction of CAD and DM risk beyond that of weight loss
alone
Recommendations based on review of 13 RCTs:
– Reduce sedentary time
– Walking or swimming at a slow pace
– Walk 30 min/day for 3 days/week, building up to 45 minutes
of more intense walking, 5 days a week
– This will add an expenditure of 100-200kcal/day
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Arch Intern Med Sept 1998;158:1855-1867
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Behavior Therapy
• Evidence that high-intensity counseling together with behavioral
interventions produces a modest, sustained weight loss
• High-intensity counseling = more than 1 person-to-person
(individual or group) session per month for at least the first 3
months
• Includes self-monitoring of eating habits and physical activity,
stress management, stimulus control, problem solving,
contingency management, cognitive restructuring, social
support; skill development, motivation, and support strategies
• Refer obese patients to programs of intensive counseling and
behavioral interventions. Concerted effort by physicians,
psychologists, dieticians, behavioral therapists, exercise
physiologists, nurses, multidisciplinary teams
USPSTF Guidelines: Screening for obesity in
adults: Recommendations and rationale
(www.guideline.gov)
American Family Physician June 1,
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Pharmacotherapy
• If 6 months of combined dietary, behavioral and physical
therapy are unsuccessful, pharmacologic therapy should
be considered:
• Approved agents
– Sibutramine
– Orlistat
• Agents approved for indications other than weight loss
• Herbal or OTC agents
• Agents still under investigation
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Pharmacologic therapy
Sibutramine
- Decreases appetite and increases metabolic rate
– Meta-analysis data shows a 4.5kg wt loss at one year
compared to placebo
– Side effects: modest increase in HR and BP, insomnia
Phentermine
– Meta-analysis: mean wt loss of 3.6kg
– Contraindications - symptomatic CAD, hyperthyroidism, HTN,
glaucoma
Diethylpropion
– Meta-analysis: mean wt loss of 3.0kg; borderline statistical
significance
Arch Intern Med 2004;164:994-1003
Lancet 352:167-172
Ann Intern Med 2005;142:532-46.
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Eur J Clin Pharmacol 46:405-10.
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Orlistat
• Lipase inhibitor – dose related increase in fecal fat starts
at dose of 200mg/day and plateaus at 400-600mg/day
• Meta-analysis data shows 2.59kg loss at 6 mo and 2.89kg
at 12 mo
• Two year studies show 52% of lost wt regained if drug
stopped, 32% of lost wt regained if drug continued
• Adverse effects – flatus, abdominal cramping, fecal
incontinence, oily spotting, potential for malabsorption of
fat soluble nutrients
• Beneficial lipid effects:
• Lowers total cholesterol 7% compared to placebo
• Lowers LDL 5% compared to placebo
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Off Label Pharmacologic Therapy
• Fluoxetine (9 studies) – higher dose than depression: 60mg
rather than 20mg
– 4.74kg at 6 months, 3.15kg at 12 months
• Topiramate (6 studies, only one published)
– No recommendations due to limited data
• Sertraline (1 study)
– Small study without statistically significant results
• Buproprion (3 studies)
– 2.77kg at 6 to 12 months
• Metformin
–
increases insulin sensitivity, decreases intestinal absorption of
glucose, and decreases hepatic glucose production
– 1996 RCT of 324 patients with upper body obesity showed 2kg wt
loss in 1yr on metformin compared to 0.8kg weight gain on placebo
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Le Z et al.
Meta-analysis: pharmacologic treatment of obesity. Ann Intern Med. 2005; 142: 532-46.
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Diabetes Care. 1996;19:920-926.
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Other Pharmacologic Options
• Herbal and OTC. There is no evidence regarding safety or
efficacy of any of these agents:
Ephedrine
5-hydroxytryptophan
Pyruvate
Aloe
Dandelion
Guar Gum
Agents under investigation:
• Cannabinoid antagonists
• B-3 adrenergic agonists
• Ghrelin, cholecystokinin A agonists, Human Growth
Hormone peptide analogs, leptin
Website address:
www.hateweight.com
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Rimonabant (Acomplia)
• Cannabinoid-1 receptor blocker
• Decreases diet induced obesity and hyperlipidemia
• Under production by Sanofi-Aventis;Currently in phase III
of development, expected to be on the market by early
2006
• RIO-Europe Study
• RIO-North America, RIO-lipids, ROI-diabetes and pooled
data not yet published; presentation available on Aventis
website with unpublished data:
--> http://en.sanofiaventis.com/Images/44_25259.pdf
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Lancet 2005 April 16-22; 365(9468): 1389-97.
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Surgical Options
Roux-en-Y gastric bypass (RTGB)
Limits gastric capacity and causes mild malabsorption
Biliopancreatic bypass
www.bariatricinstituteky.com/ procedure.html
Limited gastrectomy and long intestinal bypass causes malabsorption
http://www.yoursurgery.co
m/procedures/bariatric/im
ages/biliopancreatic.jpg
Laparoscopic adjustable gastric band
In other countries, device around uppermost stomach limits capacity
Vertical banded gastroplasty
http://northern.uhspublications.com/winter2005/i
mages/story2pic2.gif
Stapling of upper stomach to reduce capacity
http://www.bariatricinstituteky.co
m/images/stomach-stapling.gif
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Surgery Outcomes
• Weight loss: pooled data from five RCTs show that bypass
procedures result in more weight loss than banding procedures
• SOS study – evaluations of comorbid conditions including DM,
HTN, hyperlipidemia improves with surgery in association with
weight loss
• Ongoing study of incidence of CVA, MI, and cancer in control v.
surgical groups
• Mortality:
– No statistically significant difference in mortality when
comparing various procedures
– 30 day and inpatient mortality data of 62,000 procedures in
the state of WA from 1987-2001 were reported to be 1.9%.
– Inpatient mortality studies in California and Pennsylvania are
0.3% and 0.6% respectively.
– Mortality does depend on surgical center and surgical
volume.
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Guidelines - origins, endorsers, position statements
National Heart, Lung, and Blood Institute’s
Obesity Education Initiative
National Institute of Diabetes and Digestive and
Kidney Diseases (National Task Force on
the Prevention and Treatment of Obesity)
National High Blood Pressure Education Program
North American Association for the Study of
Obesity
American Heart Association
American Diabetes Association
American Academy of Pediatrics
American Association of Clinical
Endocrinologists/American College of
Endocrinology
American Obesity Association
http://www.obesity.org/
U.S. Clinical Preventive Services Task Force
Institute of Medicine
World Health Organization - International
Obesity Task Force
USPSTF
American College of Obstetricians and Gynecologists
American Dietetic Association
http://www.eatright.org
American Academy of Family Physicians
American Medical Association
For “The Clinical Guidelines on the Identification,
Evaluation, and Treatment of Overweight and
Obesity in Adults: Evidence Report” go to
http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm
www.preventiveservices.ahrq.gov
www.guideline.gov
Also…for more information…
Healthy People 2010, go to
http://www.healthypeople.gov/
The New Food Pyramid
– www.MyPyramid.gov
http://www.weightwatchers.com
Am Fam Physician 2001; 63:2185-96
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Arch Intern Med Sept 1998;158:1855-1867
Services
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References
Lyznicki JM et al. Obesity: assessment and management in primary care. American Family Physician June 1,
2001;63(11):2185-2196
National Institutes of Health’s Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults, in Arch Intern Med Sept 1998;158:1855-1867
Dansinger ML et al. Comparison of the Atkins, Ornish, Weight Watchers, and Zone Diets for Weight Loss and heart Disease
Reduction. JAMA Jan 5 2005;293(1):43-53.
Yancy WS Jr et al. A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized,
controlled trial. Ann Intern Med 2004;140:769-777
Samaha FF et al. A low-carbohydrate as compared with a low-fat diet in severe obesity. N Engl J Med 2003;348:2074-2081
Foster GD et al. A randomized trial of a low-carbohydrate diet for obesity. N Engl J Med 2003;348:2082-2090
Brehm BJ et al. A randomized trial comparing a very low carbohydrate diet and a calorie-restricted low fat diet on body weight
and cardiovascular risk factors in healthy women. J Clin Endocrinol Metab. 2003;88:1617-1623
Stern L et al. The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year followup of a randomized trial. Ann Intern Med 2004;140:778-785
Nawaz H and Katz DL. American College of preventive medicine Practice Policy Statement: Weight Management Counseling
of Overweight Adults. Am J Prev Med 2001;21(1):73-78.
McTigue KM et al. Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services
Task Force. Ann Intern Med 2003;139:933.
McTigue KM et al. Screening and interventions for obesity in adults. Systematic Evidence Review No. 21. Rockviille,
MD:Agency for Healthcare Research and Quality. December 2003. www.ahrq.gov/clinic/serfiles.htm
Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education
Services
Duke Internal Medicine Residency Curriculum
References
Arterburn et al. The efficacy and safety of sibutramine for weight loss: a systematic review. Arch Intern Med
2004;164:994-1003
Fontbonne A et al. The effect of metformin on the metabolic abnormalities associated with upper body fat
distribution. BIGPRO Study Group. Diabetes Care 1996; 19(9): 920-926.
Luc F Van Gaal, et al. Effects of the cannabinoid-1 receptor blocker rimonabant on weight reduction and
cardiovascular risk factors in overweight patients: 1-year experience from the RIO-Europe study. 2005
Lancet; 365(9468): 1389-1397.
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