American College of Physicians: Internal Medicine — Doctors for Adults ®


Diet, Drugs or surgery? The skinny on weight loss

From the June ACP Observer, copyright 2007 by the American College of Physicians.

By Stacey Butterfield

SAN DIEGO—Which is the best weight loss program—Jenny Craig? Weight Watchers? Nutri-System? Is it better to count calories or eat a lot of protein?

Ken Fijuioka, MD

Ken Fijuioka, MD

To effectively treat obesity, internists must be prepared to answer questions like these, said Ken Fujioka, MD, general internist and director of the Center for Weight Management at the Scripps Clinic in San Diego. As an obesity expert and researcher whose average patient weighs about 325 pounds, Dr. Fujioka has counseled many people on the best ways to lose weight.

"Treating obesity is by far the most difficult thing you can do in private practice," Dr. Fujioka told a large audience at Internal Medicine 2007. "But this is also something you see on a regular basis."

So which diet program is the best? They are all about equally effective, if you fit the right diet with the right patient, Dr. Fujioka said. Weight Watchers is the least expensive and effective for patients who have the time to attend meetings. Jenny Craig and Nutri-System provide prepared food, and as an Internet-only program, Nutri-System doesn't require any meeting attendance.

As for different types of diets, low-carbohydrate, low-fat, calorie counting and meal replacements are all viable options, said Dr. Fujioka. He noted a recent trial of diets, published in the Journal of the American Medical Association, which found that patients lost the most weight on the Atkins low-carb/high-protein diet.

That's probably because protein makes people feel more full, Dr. Fujioka said. "In a free-living society, high protein seems to work. When you eat protein later in the day, your brain says, 'I'm OK.'"

Obviously, it remains important to fit the diet to the dieter. "If you have a vegetarian, it's pretty tough to do a high-protein diet," he said.

After diets, try drugs

If successful, diets generally result in 5% to 10% weight loss in a year, after which the body will make metabolic adjustments to keep weight on. For further weight loss, Dr. Fujioka often suggests medication.

"The more different approaches you use, the more weight loss you can get," he said. In a 2001 study of pharmacologic treatment of obesity, published in the Archives of Internal Medicine, a combined program of diet, lifestyle change and medication showed the greatest effectiveness, he noted.

After six months in the study, overweight women who were on a diet, receiving counseling on lifestyle changes and taking sibutramine had lost an average of 17.9 kilograms. Participants in the drug plus lifestyle change group had lost 11.4 kg on average, and those on drugs alone had only dropped 5.6 kg.

Orlistat has become the most talked-about weight-loss drug since it was approved by the FDA for sale over-the-counter earlier this year, Dr. Fujioka said. Patients who choose that option should be reminded to take a multi-vitamin at least two hours apart from the drug, because it can decrease the absorption of vitamins and minerals.

When prescribing a weight-loss medication, physicians should consider the patient's comorbidities. For example, bupropion treats both depression and obesity, while the diabetes drug metformin has also been shown to induce weight loss.

Other drugs that have may effectively produce weight loss without major side effects include sibutramine and phentermine, Dr. Fujioka said. Phentermine should not be given to normal-weight females who want to get skinnier, however. "Weight loss drugs were never meant for normal-weight individuals. They were never tested in this group," he said.

It will become apparent quickly whether the prescribed drug is right for the patient. "If they don't lose four pounds in the first four weeks, it's probably not working," said Dr. Fujioka.

As options fail, surgery

For patients who are far above normal weight and haven't had success with diet, lifestyle and medication, "The best treatment, as much as I hate to admit it, is surgery," Dr. Fujioka said. He recommends, in accordance with ACP's practice guidelines, that surgery be considered only for patients with a body-mass index of 40 or more.

Laparoscopic adjustable gastric banding is gaining popularity and is Dr. Fujioka's preferred surgical treatment. It's different from the stomach stapling that fell out of favor 15 years ago, he noted, because the bands can be adjusted to continue working when patients lose weight. Soon, these adjustments will be electronic, Dr. Fujioka said.

Gastric bypass is the other NIH- and ACP-approved surgical choice, but it carries a much higher risk of morbidity and mortality. Banding has a less than 5% morbidity rate and 0.1% mortality while bypass has a 10% rate of major morbidity and 0.5% mortality. "That's a tough number to swallow because this is elective surgery," said Dr. Fujioka.

Losing weight and keeping it off is a major challenge, concluded Dr. Fujioka. Even with all of the medical advances, the best predictive factors for whether a patient will maintain weight loss come down to some very basic steps: do at least five hours a week of cardio, eat multiple small meals and don't skip breakfast.


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