A Gaining Trend: Obesity in the United States

AUGUST 01, 2004
Monica Holmberg, PharmD

Behavioral Objectives

After completing this continuing education article, the pharmacist should be able to:

  1. Describe weight gain trends in the United States since 1960 and their general effects on health.
  2. Calculate the body mass index and calories needed for weight loss or maintenance.
  3. List the strengths and limitations of low-carbohydrate and low-fat diets.
  4. Identify the 2 major weight-loss medications used in the United States.
  5. Explain how bariatric surgery contributes to weight loss.

Why are Americans gaining so much weight? According to the 1999-2000 National Health and Nutrition Examination Survey, two thirds of adults in the United States were overweight and 30.5% were obese.1 Whereas these numbers alone are disturbing, the trend that they represent is even more upsetting. From 1960 to 2000, the incidence of overweight Americans (body mass index [BMI] 25-29.9) rose from 31.5% to 33.6%, while the incidence of obesity (BMI ≥30) more than doubled from 13.3% to 30.9%.1 Even the incidence of extreme obesity (BMI ≥40) increased from 2.9% to 4.7% from 1988 to 2000.

Both sedentary lifestyles and dietary changes have played an important role in this startling trend. Less than one third of Americans participate in regular physical activity.1 Portion sizes in home, restaurant, and prepackaged meals and snacks have increased, helping to pile on the pounds, especially because most people tend to eat the entire serving. Additionally, more people are eating outside the home than in previous years, a trend that is associated with increased food intake, body weight, and body fatness.2

Obesity in the United States is a major health concern. Annual obesity-related health care costs range from $70 billion to $200 billion.3 Known complications of obesity include type 2 diabetes mellitus, hypertension, congestive heart failure, lipid disorders, arthritis, and certain types of cancers.3 Conditions associated with obesity include increased cholesterol, pregnancy complications, urinary stress incontinence, and psychological disorders.1 These conditions lead to alarming results: 300,000 deaths per year are associated with obesity, poor dietary habits, or physical inactivity.1

Determining Obesity

Traditionally, obesity was assessed using one number: the number that appeared when a person stepped on the scale (weight). Today, the determination of obesity is a more refined process, using BMI, waist circumference, and overall medical risk.4

BMI is a simple equation that assesses total body fat more accurately than body weight alone. To determine BMI, a patient's weight in kilograms is divided by the square of the patient's height in meters: BMI = weight in kg/(height in meters)2

To calculate BMI in pounds and inches, the following formula is used:

BMI = (weight in pounds X 703)/(height in inches)2

The classification of BMI values is listed in Table 1. A BMI of 18.5 to 24.9 kg/m 2 is considered normal. Values >24.9 kg/m 2 are considered overweight. Values >30 kg/m 2 are considered obese.4

Although BMI is a fast, convenient way to assess obesity, it should be used with caution in certain patients, such as those with edema, high muscularity, muscle wasting, and limited stature. Its values may not be an accurate reflection of body fatness.4 For example, a very muscular person may be classified as "overweight" when he or she is actually very fit. Conversely, a person with low muscle mass may be classified as having "healthy weight" when he or she has poor nutritional reserves. It is important to use the BMI equation as a tool in the patient's assessment and not as the entire assessment.1

Waist circumference is another important tool used in determining obesity and potential obesity-related complications. Centrally located weight has been independently linked with health risks associated with obesity, such as cardiovascular disease, type 2 diabetes mellitus, and hypertension.5 This tool is especially useful in patients who are normal or overweight, and it is insignificant in patients with a BMI of >35 kg/m 2. Women with a waist circumference of >35 inches and men with a waist circumference of >40 inches should be considered at risk for obesity-related complications.4

The pathophysiology of obesity is still being researched. The adipocyte (fat cell) has been found to secrete many hormones that influence energy metabolism. When released from the adipocyte, leptin influences energy intake through receptors on the hypothalamus. Whereas levels of leptin have been found to correlate with obesity, its role is still not completely understood, and leptin treatment is not likely to be effective in treating obesity.2 The cause of obesity is not fully understood and appears to result from a combination of social, behavioral, cultural, physiologic, metabolic, and genetic factors.4

Losing Weight

If the benefits of weight loss are obvious, why are so many Americans still overweight? Even a minimal weight reduction of 5% to 10% in overweight or obese individuals can reduce the risk of mortality and morbidity,6 a goal that can be achieved by reducing caloric intake by 500 to 1000 calories per day.7 Unfortunately, weight loss—and especially weight maintenance after weight loss—can be challenging for even the most determined individuals. Weight loss requires lifestyle modification, often through dietary changes, exercise regimens, pharmacotherapy, or a combination of all 3 approaches.


Fad diets promise and produce rapid weight loss, often with the illusion of unrestricted calorie consumption.8 For example, many a dieter has tried the infamous "Mayo Clinic Diet," a fad diet circulating for the past 30 years that is not—and never has been—supported by the Mayo Clinic. The diet has several versions and usually consists of grapefruit consumption prior to meals. Meals range from salad to bacon, depending on the variation of the diet. Despite its nutritional inconsistency, the selling point of the diet remains the elusive promise of weight loss with the false endorsement of the Mayo Clinic.9 Weight loss associated with fad diets, however, is rarely sustainable, and the long-term health implications of fad diets are rarely studied. In spite of their popularity, clinicians should caution patients away from the use of fad diets.8

General health guidelines for weight loss suggest increasing activity, decreasing dietary fat, and decreasing dietary sugar.10 A 1-lb weight loss requires a dietary deficit of 3500 calories. Reduction of calorie consumption by 500 to 1000 calories per day can result in a 1- to 2-lb weight loss per week, the amount generally recommended by health care professionals.4 Although conventional weight-loss regimens have involved an energy-deficient diet high in carbohydrate and low in fat, recent dieting trends suggest the opposite: a low-carbohydrate diet (<10% of daily calories coming from carbohydrates) and unrestricted fats and proteins.

Low-Carbohydrate Diets

The Atkins diet, originally published in 1973 and republished in 1992 and 2002, is a popular example of a low-carbohydrate diet. The diet promotes 10% of the total daily caloric intake from carbohydrates and ~40% from fat. An average diet usually derives ~30% of its calories from fat.11 Four times as many dieters have read Robert Atkins' diet book as any other diet book. Individuals likely to turn to Atkins' book are those shying away from prescription treatment, having minimal health care provider contact, and looking for a self-help solution to weight management.12

The Atkins Nutritional Approach promotes a nutrient-rich diet consisting of unprocessed food and vitamin supplementation, along with restriction of processed or refined carbohydrates. Examples of restricted carbohydrates include high-sugar foods, breads, pasta, cereal, and starchy vegetables. The regimen consists of 4 phases: Induction, Ongoing Weight Loss, Pre-Maintenance, and Lifetime Maintenance.13

During the Induction phase, which is the first 14 days on the Atkins diet, carbohydrate intake is limited to <20 g/day.12 These first 2 weeks are promoted to take the weight off quickly by inducing the body into ketosis, as stored fat is consumed for energy.13 In this phase, however, weight loss may be partially due to diuresis, which would artificially inflate weight-loss results.8

After 2 weeks, the Ongoing Weight Loss phase begins, at which point the dieter slowly adds carbohydrates back into the diet at a rate slow enough to continue weight loss.13 Once the goal weight is achieved, total daily carbohydrate intake may be increased as appropriate.12

The Pre-Maintenance phase prepares the dieter for long-term dietary changes to maintain the weight loss by slowly adding carbohydrates to the diet at a rate of 10 g/week. The Lifetime Maintenance phase is an individualized guideline for low-carbohydrate dietary balance aimed at maintaining weight loss.13

A current and extremely popular diet is the South Beach Diet. This diet proclaims to be neither "low-carb nor low-fat" and advocates weight loss through restriction of "bad carbs" and "bad fats." Despite its proclamations to the contrary, the South Beach Diet is similar to the Atkins diet in its 3-phase plan of carbohydrate restriction and gradual reintroduction. The first phase lasts for 2 weeks and consists of a diet of meats, fish, shellfish, nuts, eggs, and cheese. Bread, rice, potatoes, pasta, fruit, and alcohol are not allowed during this phase. During phase 2, carbohydrates are slowly brought back into the diet at a rate that still allows weight loss. The final phase focuses on dietary balance to ensure weight maintenance.14

The pathophysiology of weight loss from carbohydrate restriction involves the body's mobilization of glycogen from the liver and the muscle, resulting in energy derived from gluconeogenesis. Dietary and endogenous fat are broken down into ketone bodies, which function as energy. When this process is combined with calorie restriction, weight loss occurs.8 Calorie restriction probably results from the monotony and simplicity of the diet, increased satiety with high-fat and high-protein foods, and other factors affecting appetite.12 Low-carbohydrate diets are said to promote lipid oxidation, promote satiety, and increase energy expenditure.15 Additional weight loss after the Induction phase, however, is believed to be due to calorie restriction, not changes in the body's metabolism.8

There are limits associated with the low-carbohydrate diets. First, diets high in fat, especially saturated fat, have been linked with certain cancers, increased plasma lipids, insulin resistance, glucose intolerance, and obesity. Second, increased fat intake may be associated with cardiovascular risks that have not yet been studied. Third, long-term effects of ketosis have not been studied. Lastly, low-carbohydrate diets are rarely studied for longer than 6 months, so long-term cardiovascular and renal effects have not been established.15

Current evidence supports a diet consisting of low saturated fat and high complex carbohydrates from fruit, vegetables, and whole grains to decrease the risk of hypertension, cancers, coronary heart disease, and hypercholesterolemia.2 Fibers found in complex carbohydrates help to lower cholesterol and insulin secretion. Avoidance of these foods may actually impede dieting and health goals.8

Scientific Proof

In one of the longest studies available of the Atkins diet, 63 subjects were randomized to either a low-calorie, high-carbohydrate diet or the Atkins' low-carbohydrate, high-protein and high-fat diet. The low-carbohydrate dieters were given a copy of Dr. Atkins' New Diet Revolution and met with a registered dietitian before beginning the study. The low-calorie, high-carbohydrate group participants also met with a registered dietitian prior to the study and were given copies of The LEARN Program for Weight Management, which is consistent with the Department of Agriculture's Food Guide Pyramid. Their diet consisted of ~1200 to 1500 calories per day for women and ~1500 to 1800 calories per day for men, with 60% of daily calories from carbohydrates, 25% from fat, and 15% from protein.

At 3 months into the study, the low-carbohydrate group had lost more weight 6.8 ± 5.0 kg versus 2.7 ± 3.7 kg for the low-calorie group. At the end of 1 year, however, the difference in weight loss between the 2 groups was no longer statistically significant.12

These findings are important in their implication for long-term weight-loss outcomes associated with the low-carbohydrate diet. Although carbohydrate restriction resulted in a faster weight loss, the end result was eventually the same. The researchers determined that the weight loss was likely secondary to calorie restriction, despite unrestricted intake of fat and protein. This result suggests that macronutrient restriction does not affect weight loss in a calorie-deficient diet.12

Another potential concern with low-carbohydrate diets is the effect of increased dietary fat on the lipid profile. After 1 year, there was no significant difference in total cholesterol or low-density-lipoprotein (LDL) cholesterol between the 2 groups. The low-carbohydrate group, however, displayed a greater decrease in triglycerides and a greater increase in high-density lipoprotein (HDL) cholesterol.12

Low-carbohydrate diets have been promoted as improving insulin sensitivity. Complications of insulin resistance include atherosclerotic processes, such as inflammation, decreased size of LDL particles, and endothelial dysfunction.16 After 6 months, both groups had a significant increase in insulin sensitivity. There was no significant difference in insulin sensitivity after 1 year, suggesting that, in nondiabetic patients, macronutrient restriction does not affect insulin sensitivity.12

Despite these findings, the researchers still feel that more long-term studies are needed to determine whether the benefits of the Atkins diet outweigh the risks for coronary heart disease in obese individuals. Interestingly, ~40% of the participants dropped out of the study: 43% dropped out of the high-carbohydrate diet group and 39% dropped out of the low-carbohydrate diet group.12 The high dropout rate in both groups may be due to difficulty adhering to any diet modifications.2

In other research, 53 obese females participated in a 6-month study to compare weight loss and cardiovascular risks from a low-fat diet recommended by the American Heart Association, versus a low-carbohydrate diet. The low-fat diet consisted of 54% of total daily calories from carbohydrate, 18% from protein, and 28% from fat. The low-carbohydrate group consumed 15% of their total daily calories from carbohydrates, 28% from protein, and 57% from fat.

After 3 months, the low-fat-diet group had lost 4.2 ± 0.8 kg, while the low-carbohydrate group had lost 7.6 ± 0.7 kg. After 6 months, the low-fat group had lost 3.9 ± 1.0 kg, and the low-carbohydrate group had lost 8.5 ± 1.0 kg. Seven participants in the low-fat group and 4 in the low-carbohydrate group discontinued the study. Both groups had decreased total cholesterol, LDL, and triglycerides, along with increased HDL, suggesting that the low-carbohydrate diet was both safe and effective as a short-term weight-loss mechanism. The authors of the study, however, acknowledged that studies longer than 6 months are necessary to determine long-term effects of carbohydrate restriction on weight loss and cardiovascular risk.15

Low-Fat Diets

Whereas the low-carbohydrate diet is popular now, dieting trends also have embraced its opposite: the low-fat diet. Dietary fat has been believed to contribute to obesity by being used and stored more efficiently than carbohydrates and consumed in excess.2 Individuals following a low-fat diet are encouraged to consume <10% of their total daily caloric intake from fat. Dietitians and health experts promote high intake of fiber-rich complex carbohydrates, such as brown rice, fruits, vegetables, whole grains, and natural legumes, because these foods increase satiety and contain fewer calories. Fiber also slows the absorption of food from the gastrointestinal tract, preventing a rapid rise in blood sugar, which in turn prevents an insulin response.11

As with all diets, misconceptions have arisen with this diet. Many individuals adhering to a low-fat diet incorrectly believe that only fat calories cause weight gain, leading to an overindulgence of grains and starches. Increased caloric intake, no matter where the calories come from, can result in weight gain 11 (Table 2; Sidebar: The Old-Fashioned Solution—Calorie Counting).

Other Dieting Trends

Other popular diets include a high-calcium diet, especially from dairy products, to promote weight loss. Although calcium intake has obvious health benefits, its role in weight loss needs further clinical investigation.2

Advocates of high-protein diets suggest that increased protein correlates with increased satiety and increased thermic effect from food. Again, little evidence exists to support this theory, and the effects of high protein intake on renal function and calcium balance are unknown but are worthy of concern.2 Whereas a definite link has yet to be established, epidemiologic data show a direct relationship between worsening kidney function and high protein consumption in women with preexisting renal insufficiency. Additionally, a tentative link exists between high dietary protein and microalbuminuria in individuals with diabetes and hypertension.17

Interestingly, a moderately increased protein diet has been found to prevent weight regain after significant weight loss. A total of 148 individuals who had successfully lost 5% to 10% of their body weight were randomized to consume 15% or 18% of their calories from protein. The authors hypothesized that weight regain could be minimized by increasing protein consumption by 20% (from a standard dietary baseline of 15%-18%). After 3 months, the group consuming the higher rate of protein regained 50% less weight than the lower-protein group.6


Weight loss can be simplified to a game of numbers: calories consumed must be less than calories burned. Exercise and weight loss appear to have a direct dose-dependent relationship: as exercise increases, so does weight loss. Burning calories creates an energy deficit, which leads to weight reduction. In fact, even without calorie restriction, exercise can result in weight loss.5

Yet, how much exercise is needed? Unfortunately, there is no concrete answer. It has been hypothesized that the first 6 to 7 miles of exercise a week are necessary just to prevent weight gain. In 1995, the Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine recommended 30 minutes of moderate-intensity physical activity on most, if not all, days of the week to prevent weight gain. The Institute of Medicine of the National Academies, however, recently increased that recommendation to 60 minutes a day.5 The CDC recommends an energy expenditure of ~1000 calories per week, or 150 minutes per week of moderate-or-greater-intensity exercise.18

A randomized, multicenter study of 202 overweight subjects compared exercise in 2 groups: one group with an energy expenditure of 1000 calories per week; the other group with an energy expenditure of 2500 calories per week. After 6 months, the weight loss in the 2 groups was essentially the same. After 18 months, however, the high-energy-expenditure group had lost more weight—and kept the weight off—compared with the lower-expenditure group.18

Exercise is crucial in long-term maintenance after weight loss.5,7 Many clinicians suggest walking as an initial exercise program, especially for the individual dreading time on the treadmill at a local gym. Walking is a safe and accessible form of exercise that most people can fit into their schedule. Patients beginning to walk should be advised to start with a modest routine, such as 10 minutes 3 days a week, and to slowly increase their time and duration toward a goal of 30 to 45 minutes on most or all days.4 The use of pedometers is a current trend making a dramatic difference in exercise habits. Working out with a group or a friend has been shown to increase compliance. A buddy system should be suggested to individuals struggling with an exercise program.18

In addition to preventing weight regain, regular exercise has been shown to decrease the risk of developing cardiovascular disease and type 2 diabetes. The benefit is greater than that from weight loss alone.4


In 1999, Americans spent $321 million on obesity medications. Although lifestyle changes, such as diet and exercise plans, are considered first-line therapy, certain patients may require more intensive treatment. Pharmacologic intervention is recommended in patients with a BMI of ≥30 or in patients with a BMI of ≥27 who also have obesity-related risk factors or disease states.4

Weight-loss medication historically was advocated as a short-term treatment to induce behavior modification, thus resulting in weight loss. This technique, however, was rarely successful. In 1992, Weintraub et al7 released a study supporting long-term pharmacotherapy that changed the role of weight-loss medications. The study found that weight loss was maintained for up to 3 1/2 years for patients on continuous medication. Although the agents in the study, fenfluramine and phentermine, are no longer available due to associated valvular heart disease, the results of the study revolutionized weight-loss standards. Instead of being perceived as a personal weakness, obesity gained status as a chronic disease state, complete with medication treatment.7

Currently, the only prescription medications approved by the FDA for long-term weight loss are sibutramine (Meridia) and orlistat (Xenical).4


Sibutramine acts centrally to inhibit the reuptake of serotonin and norepinephrine, resulting in the control of food intake by delaying meals or causing earlier satiety.19 It is approved for use for up to 2 years and should be used with a reduced-calorie diet.20 Sibutramine typically is given as 10 to 15 mg daily. Patients unable to tolerate the 10-mg dose may be switched to 5 mg.

Potential side effects include insomnia, dry mouth, asthenia, and constipation.19 Approximately 5% of patients using sibutramine discontinue the drug secondary to side effects.7 Because sibutramine may cause a significant increase in blood pressure, regular monitoring is required.20 Patients with a history of coronary heart disease, congestive heart failure, cardiac arrhythmia, or stroke or patients who are currently taking a monoamine oxidase inhibitor or a selective serotonin reuptake inhibitor should not take sibutramine. Sibutramine is metabolized by the CYP3A4 P450 enzyme system, and caution should be used with inhibitors of that system, such as ketoconazole and erythromycin.20


Orlistat is effective in establishing weight loss and slowing weight regain7 by inhibiting the absorption of dietary fats in the lumen of the stomach and small intestine, thus resulting in reduced calorie intake and weight control. Orlistat is given as 120 mg 3 times a day with each fat-containing main meal. Higher doses have not shown greater benefit. Patients using orlistat should be advised to maintain a balanced, reduced-calorie diet with approximately 30% of the total daily calories from fat.21

Gastrointestinal symptoms—including oily spotting, flatus with discharge, fecal urgency, fatty stool, oily evacuation, increased defecation, and fecal incontinence—have been the most commonly observed side effects. They usually last between 1 and 4 weeks of beginning therapy.21

Although orlistat may be a safe, effective tool for weight loss or maintenance in some patients, it is not appropriate for everyone. Orlistat should not be given to patients with chronic malabsorption syndrome or cholestasis. Because orlistat has been shown to reduce the absorption of certain fat-soluble vitamins, patients taking orlistat also should take a multivitamin containing fat-soluble vitamins. Concurrent administration of orlistat and cyclosporine has been shown to result in decreased cyclosporine levels, and coadministration, if unavoidable, should be carefully monitored.21

The mechanisms of sibutramine and orlistat differ significantly: one decreases appetite, whereas the other prevents fat absorption. What are their differences in terms of weight loss? In one study comparing the efficacy of sibutramine to that of orlistat, 150 women were randomized into 3 groups: one group taking sibutramine 10 mg twice a day, another taking orlistat 120 mg 3 times a day, and the third taking metformin 850 mg twice a day. All 3 groups experienced a decrease in BMI, with the sibutramine group decreasing BMI the most (13.57% vs 9.06% for orlistat and 9.90% for metformin).22 It is important to note, however, that the sibutramine dose used in the study exceeded that recommended by the manufacturer.

Another study evaluated orlistat's effect on additional weight loss in patients who had been using sibutramine for a year. In a randomized, double-blind study, 34 women who had successfully lost 11.6% ± 9.2% of their body weight during a year of sibutramine therapy were assigned to either sibutramine plus orlistat or sibutramine plus placebo. After 16 weeks, neither group had a significant change in body weight, suggesting that combination therapy after moderate weight loss was no more effective than sibutramine therapy alone.23


Whereas prescription medications are available and effective for the treatment of obesity, many Americans will turn to OTC medications before consulting a doctor or dealing with high prescription costs. Among the most popular OTC therapies for weight control have been herbal supplements containing ephedrine alkaloids.24 Although ephedrine is no longer available for sale in the United States, it is important for health care providers to be aware of the prevalence of ephedrine and its potential dangers.

Ephedrine, an adrenergic agent, exerts both appetite-suppressant and thermogenic effects.7 Ephedrine alkaloids, known as ma huang or Chinese ephedra, are found naturally in plants.25 Other names include desert herb, joint fir, popotillo, sea grape, or yellow horse.26

Ephedrine alkaloids are similar to amphetamines. Their major active ingredient strongly stimulates the heart and nervous system, resulting in increased blood pressure and circulatory system stress.25 A recent review of available data on ephedrine showed that the significant risk of heart problems and stroke did not outweigh the benefit of short-term weight loss.25 A study of calls to poison control centers, however, reported a higher rate of calls in response to ephedra than to other herbal supplements. Ephedra accounted for 64% of all calls regarding adverse reactions to commonly used herbs.26

Adverse effects associated with the use of ephedra include cardiovascular events such as hypertension, stroke, myocardial infarction, and fatal arrhythmias.26 As a result of ephedra's danger to consumers, the FDA banned the sale of dietary supplements containing ephedrine alkaloids as of April 12, 2004. Patients continuing to use ephedrine for weight control should be encouraged to stop 29 (see Sidebar: OTC Weight-Loss Products—Worth the Risk?).

Bariatric Surgery

Although it is a drastic extreme and is not intended for all dieters, bariatric surgery is a weight-loss option that is gaining popularity and that should be considered for appropriate patients. Its recent prevalence results from a combination of public awareness, advanced technology, shorter hospital stays, and quicker recovery times. The frequency of bariatric surgery more than doubled in the span of 1 year—from 40,000 procedures in 2001 to 86,000 in 2002.31 More than 100,000 patients are expected to undergo bariatric surgery in 2004.32

Nationally accepted requirements for bariatric surgery include a BMI of ≥40, a BMI of ≥35 with certain comorbidities— such as severe sleep apnea, hypertension, cardiomyopathy related to obesity, severe diabetes mellitus, or musculoskeletal or neurologic concerns— and a long-term history of obesity, multiple failed weight-loss attempts, and compliance with dietary and behavioral changes as recommended by the medical team. Contraindications for bariatric surgery include a history of an eating disorder or psychological instability.31 As a result of weight loss, bariatric surgery often improves the patient's comorbidities, such as type 2 diabetes, hypertension, heart disease, gastroesophageal reflux disease, sleep disorders, arthritis or joint pain, and asthma.31

The most commonly used weightloss surgeries are vertical banded gastroplasty, which reduces gastric volume, and Roux-en-Y gastric bypass, which limits food intake and alters digestion.4,31 Bypass, a combination restrictive and malabsorptive procedure, is done more frequently in the United States, because it tends to result in longer weight maintenance.32 Bypass procedures have produced weight loss for up to 14 years and up to 68% of excess weight.33


Obesity is impacting more Americans now than ever before. Perhaps the most unsettling aspect is the rapidly increasing trend of obesity: Americans have gained—and are gaining—more weight now than in previous years. Obesity needs to be perceived as a chronic disease with resulting comorbidities and complications.

Individuals ready to implement dietary changes should be encouraged and educated on healthy lifestyle changes. Providers interacting with dieters need to be aware that fad diets and diet supplements may be ineffective and even dangerous. For many, regimens such as a low-carbohydrate diet provide an eating habit guideline and effective weight loss. When diet changes alone will not produce weight loss, pharmacotherapy needs to be considered. Although still viewed as a last resort, bariatric surgery is becoming a more commonplace option for patients who are unresponsive to lifestyle modification and pharmacotherapy to treat obesity and to prevent its complications.

The Old-Fashioned Solution—Calorie Counting

Most people have no idea how many calories they consume daily. An easy way to confirm this fact is to ask 10 people who are carrying some excess weight. Most will avoid answering the question, and, if they do offer an answer, their answer will most likely be on the low side. Dietitians recommend keeping a food diary for a week. They ask patients to log every morsel of food consumed in a diary that indicates when they eat and the total number of calories they consume. Sometimes, they ask patients to record triggers to eating, as well as periods of exercise. At the end of the week, they work with the patient to determine the patient's unique problems. Then, they determine a reasonable number of target calories for weight loss, identify healthy choices, structure food intake and exercise programs, and ask the patient to maintain the food diary until he or she has established healthy habits.

Potential dieters can monitor themselves, using any number of readily available tools. This technique is the basis for the Weight Watchers program that uses a point system. Dieters must know their target weight and the maximum number of calories they are allowed to reduce their weight. Some of the premises seem simple, but they are remarkably effective:

  • Dietitians discourage skipping meals, especially breakfast, because severe hunger will prompt the dieter to overindulge
  • Increasing dietary intake of fruits and vegetables to 5 to 7 servings daily is essential and improves health in many ways
  • Adequate fluid intake (64 oz daily) is advised, to maintain hydration and reduce hunger
  • Balancing protein, fat, and carbohydrates also is advised
  • As dieters lose weight, gradual calorie reduction will be necessary. Thus, a 63-in-tall woman aged 46 years weighing 170 lb needs ~2200 calories daily to maintain her weight. If she consumes ~1700 calories a day, she will lose 1 lb a week. When she reaches 150 lb, she will need ~2000 calories a day for maintenance and will need to reduce her consumption to 1500 to continue losing. Should she attain a target weight of 136 lb, she will be able to consume 1950 calories daily and maintain this weight. So, as people lose weight, they need to reduce intake gradually. (Stepping up her exercise from a moderate to a high level will allow this woman to eat 300 extra calories.)
  • A 6-ft-tall man aged 46 years who weighs 250 lb and exercises moderately needs 3300 calories to maintain his weight. Should he reduce his intake and lose 25 lb, he will need 3100 calories to maintain his weight. If he reaches his target weight of 185 lb, he can consume 2750 calories daily and maintain his weight. (Again, increasing exercise to a high level allows him to eat another 300 calories daily and maintain his weight.)

Dieting this way is easier now that the FDA requires manufacturers to include nutritional information on product labels. Some dieters are amazed when they realize how small a serving is. Alternatively, several Web sites list foods and their calories and nutritional content. One such site that is very helpful is Calorie Chart at http://www.caloriecountercharts.com/chart1a.htm.

In addition, numerous sites offer free calorie calculators. "Free Weight Loss Tips," available at http://www.weighlosstipsfree.com/weight_loss_tips_calorie_calculator.htm, was used to calculate the examples used above. Other calculators are available at www.dietitian.com/ibw/ibw.html or at a host of other sites.

OTC Weight-Loss Products—Worth the Risk?

The dieting world has become inundated with OTC products promising rapid weight loss. Advertisements for weight-loss supplements bombard us on television, on the Internet, and in magazines. Unfortunately, the safety and the efficacy of many of these products are questionable. Be prepared when a patient asks about an OTC weight-loss aid!

Examples of OTC diet aids with poorly established health and dieting benefits are as follows:

  • Fiber tablets: These tablets are advocated to bind with fats, preventing their absorption and thereby decreasing calorie consumption.
  • Liquid diet: For instance, the "Hollywood 48 Hour Miracle Diet" is promoted to result in up to a 10-lb weight loss in 48 hours. The dieter drinks nothing but water and the "miracle juice," supposedly clearing the body of toxins and fat. Anecdotal side effects include palpitations, diarrhea, and headache, with weight loss resulting from water loss.27
  • Diuretics: Examples are caffeine and pamabrom. The resulting weight loss is due to water loss, not fat loss, providing false hope and even the danger of dehydration to dieters.
  • Apple cider vinegar tablets: These tablets are promoted to aid in weight loss, but minimal weightloss data are available, and safety and efficacy have yet to be established. 28
  • Green tea extract: This product is promoted to increase energy expenditure and fat oxidation, resulting in weight loss, but its safety and efficacy are still undetermined.
  • Grapefruit capsules: These capsules are administered twice a day with meals, supposedly inducing the individual's metabolism to burn fat more quickly and more efficiently. Safety and efficacy have not been established.29
  • Starch/carbohydrate blockers or interceptors: These agents prevent absorption of carbohydrates, resulting in decreased caloric intake. Minimal supporting scientific data exist, however.30

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. A. Stahl, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: astahl@mwc.com.

Monica Holmberg, PharmD: Phoenix Indian Medical Center, Phoenix, Ariz

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(Based on the article starting on page 66.) Choose the 1 most correct answer.

1. According to recent data, what fraction of Americans participates in regular physical activity?

  1. Less than one half
  2. Less than one third
  3. More than one half
  4. All Americans participate in regular exercise.

2. How many deaths per year are associated with obesity, poor dietary habits, or physical inactivity?

  1. 3000
  2. 30,000
  3. 300,000
  4. 3,000,000

3. What is the body mass index (BMI) equation?

  1. weight in kg/(height in meters)2
  2. (weight in kg)2/(height in meters)
  3. weight in kg/height in meters
  4. (weight in kg)2/(height in meters)2

4. BMI should be used with caution with which type of patients?

  1. Patients with muscle wasting
  2. Patients using weight-loss pharmacotherapy
  3. Patients with pneumonia
  4. Patients who have successfully lost 10% of their body weight

5. A 1-lb weight loss requires a dietary deficit of how many calories?

  1. 1000
  2. 2300
  3. 3500
  4. 4700

6. Weight loss from carbohydrate restriction results from:

  1. The body's mobilization of glycogen from the liver and the muscle.
  2. Energy derived from gluconeogenesis.
  3. Caloric restriction.
  4. All of the above.

7. Short-term studies have shown low carbohydrates to increase total cholesterol, low-density lipoprotein cholesterol, and triglycerides while decreasing high-density lipoprotein cholesterol.

  1. True
  2. False

8. Limits associated with low-carbohydrate diets include the following:

  1. Diets high in fat have been linked to certain cancers.
  2. Increased fat intake may be associated with cardiovascular risks that have not yet been studied.
  3. Low-carbohydrate diets are rarely studied for longer than 6 months, preventing the study of long-term cardiovascular and renal effects.
  4. All of the above

9. A common misconception with the low-fat diets is that:

  1. Diets low in saturated fat have cardiovascular benefits.
  2. Only fat calories cause weight gain, allowing unlimited intake of grains and starches.
  3. Fiber-rich complex carbohydrates increase satiety.
  4. Fiber prevents an insulin response by slowing food absorption.

10. Increased dietary intake of which macronutrient has been shown to prevent weight regain after significant weight loss?

  1. Protein
  2. Fat
  3. Carbohydrate
  4. Alcohol

11. Weight loss occurs when fewer calories are consumed than are burned.

  1. True
  2. False

12. How much daily exercise does the Institute of Medicine of the National Academies recommend?

  1. 30 minutes
  2. 60 minutes
  3. 90 minutes
  4. 120 minutes

13. In addition to preventing weight regain, regular exercise has been shown to decrease the risk of developing cardiovascular disease and type 2 diabetes.

  1. True
  2. False

14. Sibutramine induces weight loss by:

  1. Inhibiting the reuptake of serotonin.
  2. Inhibiting the reuptake of norepinephrine.
  3. Causing meals to be delayed.
  4. All of the above.

15. Regarding sibutramine, which of the following is not true?

  1. Regular blood pressure monitoring is required.
  2. It is metabolized by the P450 CYP3A4 system.
  3. It is safe to use with monoamine oxidase inhibitors.
  4. Caution should be used in patients with a history of arrhythmias.

16. Orlistat induces weight loss by:

  1. Promoting early satiety.
  2. Inhibiting the absorption of dietary fats in the stomach and small intestine.
  3. Inhibiting the reuptake of serotonin.
  4. Inhibiting the reuptake of norepinephrine.

17. Which is not a common gastrointestinal side effect of orlistat?

  1. Constipation
  2. Fatty stool
  3. Flatus with discharge
  4. Fecal incontinence

18. Ephedrine is a safe, effective means of weight loss.

  1. True
  2. False

19. Nationally accepted requirements for bariatric surgery include which of the following?

  1. BMI of ≥40
  2. BMI of ≥35 with certain comorbidities
  3. BMI of ≥30 with certain comorbidities
  4. a and b

20. In addition to weight loss, patients undergoing bariatric surgery have demonstrated an improvement in comorbidities, such as diabetes, hypertension, and heart disease.

  1. True
  2. False