Stage 1: Prevention Plus is defined as a first step, in which overweight and obese patients and their families focus on basic healthy lifestyle eating and activity habits (e.g., 60 min of physical activity per day; 5 or more fruit and vegetables, etc.) that form the obesity prevention strategies. The Prevention Plus stage of obesity treatment can take place in the office setting by physicians, advanced practice nurses, physician assistants, and office nurses, with appropriate training.
Stage 2: Structured Weight Management is distinguished from Stage 1 Prevention Plus by the support and structure provided to the child to achieve healthy lifestyle behaviors. Specific eating and activity goals such as a planned diet or daily eating plan, planned, supervised physical activity or active play for 60 minutes per day and monitoring of these behaviors through use of logs. For implementation of structured weight management, the following points should be noted.
the eating plan requires a dietitian or a clinician who has received additional training in creating this kind of eating plan for children
office staff members who have some training in motivational interviewing and in teaching of monitoring and reinforcement techniques can establish initial goals with families and see them for follow-up care
a counselor is available for some families who need help with parenting skills, resolution of family conflict, or motivation
depending on the child and family, referral to a physical therapist or exercise therapist can help the child and family develop physical activity habits
monthly office visits are probably most appropriate at this level
a provider's office staff can provide much of this treatment, with some additional training
group sessions may be included
Stage 3: Comprehensive Multidisciplinary Intervention increases the intensity of behavior changes, the frequency of visits, and the specialists involved, to maximize support for behavior changes. Generally, this type of program would exceed the capacity of a primary care office to offer within the typical visit structure. However, an office or several offices could organize specialists to offer this kind of a program. For implementation of comprehensive multidisciplinary intervention, the following points should be noted.
the structured program in behavior modification should include, at a minimum, food monitoring, short-term diet and physical activity goal setting, and contingency management
negative energy balance resulting from structured dietary and physical activity changes is planned
parental participation in behavior modification techniques is needed for children <12 years of age. Parental involvement would be progressively less with older youths
parents should be trained regarding improvement of the home environment
systematic evaluation of body measurements, diet, and physical activity should be performed at baseline and at specified intervals throughout the program (suggest)
a multidisciplinary team with experience in childhood obesity, including a behavioral counselor (for example, social worker, psychologist, other mental health care provider, or trained nurse practitioner), registered dietitian, exercise specialist (physical therapist or other team member with training or a community program prepared to assist obese children), and primary care provider who continues to monitor medical issues and maintains a supportive alliance with the families, should be involved
frequent office visits should be scheduled; weekly visits for a minimum of 8 to 12 weeks seem to be most efficacious. Subsequently, monthly visits can help maintain new behaviors
group visits may be more cost-effective and have therapeutic benefit
an established pediatric weight management program may be best suited to provide this type of intervention, although such programs are sparse and often are not covered by insurance plans
commercial weight management programs can be considered, but the primary care provider's office needs to screen the programs to ensure that the approach is healthy and appropriate for the age of the child. Information to guide this evaluation is included in the treatment report
Stage 4: Tertiary Care Intervention
The intensive interventions in this category may be offered to some severely obese youths. These interventions (medications, very low-calorie diets, surgery) move beyond the goal of balanced healthy eating and activity habits that are the core of the other stages.
Diagnosis
If your BMI is in the obese range, your health care provider will typically review your health history in detail, perform a physical exam and recommend some tests.
These exams and tests generally include:
Taking your health history. Your doctor may review your weight history, weight-loss efforts, exercise habits, eating patterns, what other conditions you've had, medications, stress levels and other issues about your health. Your doctor may also review your family's health history to see if you may be predisposed to certain conditions.
A general physical exam. This includes also measuring your height; checking vital signs, such as heart rate, blood pressure and temperature; listening to your heart and lungs; and examining your abdomen.
Calculating your BMI. Your doctor will check your body mass index (BMI) to determine your level of obesity. This should be done at least once a year. Your BMI also helps determine your overall health risk and what treatment may be appropriate.
Measuring your waist circumference. Fat stored around your waist, sometimes called visceral fat or abdominal fat, may further increase your risk of diseases, such as diabetes and heart disease. Women with a waist measurement (circumference) of more than 35 inches (80 centimeters, or cm) and men with a waist measurement of more than 40 inches (102 cm) may have more health risks than do people with smaller waist measurements. Like the BMI measurement, your waist circumference should be checked at least once a year.
Checking for other health problems. If you have known health problems, your doctor will evaluate them. Your doctor will also check for other possible health problems, such as high blood pressure and diabetes.
Blood tests. What tests you have depend on your health, risk factors and any current symptoms you may be having. Tests may include a cholesterol test, liver function tests, a fasting glucose, a thyroid test and others. Your doctor may also recommend certain heart tests, such as an electrocardiogram.
Gathering all this information helps you and your doctor determine how much weight you need to lose and what health conditions or risks you already have. And this will guide treatment decisions.
Treatment
The goal of obesity treatment is to reach and stay at a healthy weight. You may need to work with a team of health professionals — including a dietitian, behavior counselor or an obesity specialist — to help you understand and make changes in your eating and activity habits.
The initial treatment goal is usually a modest weight loss — 3 to 5 percent of your total weight. That means that if you weigh 200 pounds (91 kg) and are obese by BMI standards, you would need to lose only about 6 to 10 pounds (2.7 to 4.5 kg) for your health to begin to improve. However, the more weight you lose, the greater the benefits.
All weight-loss programs require changes in your eating habits and increased physical activity. The treatment methods that are right for you depend on your level of obesity, your overall health and your willingness to participate in your weight-loss plan.
Other treatment tools include:
Dietary changes
Exercise and activity
Behavior change
Prescription weight-loss medications
Weight-loss surgery
Dietary changes
Reducing calories and practicing healthier eating habits are vital to overcoming obesity. Although you may lose weight quickly at first, slow and steady weight loss over the long term is considered the safest way to lose weight and the best way to keep it off permanently.
Avoid drastic and unrealistic diet changes, such as crash diets, because they're unlikely to help you keep excess weight off for the long term.
Plan to participate in a comprehensive weight-loss program for at least six months and in the maintenance phase of a program for at least a year to boost your odds of weight-loss success.
There is no best weight-loss diet. Choose one that includes healthy foods that you feel will work for you. Dietary changes to treat obesity include:
Cutting calories. The key to weight loss is reducing how many calories you take in. You and your health care providers can review your typical eating and drinking habits to see how many calories you normally consume and where you can cut back. You and your doctor can decide how many calories you need to take in each day to lose weight, but a typical amount is 1,200 to 1,500 calories for women and 1,500 to 1,800 for men.
Feeling full on less. The concept of energy density can help you satisfy your hunger with fewer calories. All foods have a certain number of calories within a given amount (volume). Some foods — such as desserts, candies, fats and processed foods — are high in energy density. This means that a small volume of that food has a large number of calories. In contrast, other foods, such as fruits and vegetables, have lower energy density. These foods provide a larger portion size with a fewer number of calories. By eating larger portions of foods that have fewer calories, you reduce hunger pangs, take in fewer calories and feel better about your meal, which contributes to how satisfied you feel overall.
Making healthier choices. To make your overall diet healthier, eat more plant-based foods, such as fruits, vegetables and whole-grain carbohydrates. Also emphasize lean sources of protein — such as beans, lentils and soy — and lean meats. If you like fish, try to include fish twice a week. Limit salt and added sugar. Stick with low-fat dairy products. Eat small amounts of fats, and make sure they come from heart-healthy sources, such as olive, canola and nut oils.
Restricting certain foods. Certain diets limit the amount of a particular food group, such as high-carbohydrate or full-fat foods. Ask your doctor which diet plans have been found effective and which might be helpful for you. Drinking sugar-sweetened beverages is a sure way to consume more calories than you intended, and limiting these drinks or eliminating them altogether is a good place to start cutting calories.
Meal replacements. These plans suggest that you replace one or two meals with their products — such as low-calorie shakes or meal bars — and eat healthy snacks and a healthy, balanced third meal that's low in fat and calories. In the short term, this type of diet can help you lose weight. Keep in mind that these diets likely won't teach you how to change your overall lifestyle, though, so you may have to keep this up if you want to keep your weight off.
Be wary of quick fixes. You may be tempted by fad diets that promise fast and easy weight loss. The reality, however, is that there are no magic foods or quick fixes. Fad diets may help in the short term, but the long-term results don't appear to be any better than other diets.
Similarly, you may lose weight on a crash diet, but you're likely to regain it when you stop the diet. To lose weight — and keep it off — you have to adopt healthy-eating habits that you can maintain over time.
Exercise and activity
Increased physical activity or exercise is an essential part of obesity treatment. Most people who are able to maintain their weight loss for more than a year get regular exercise, even simply walking.
To boost your activity level:
Exercise. People who are overweight or obese need to get at least 150 minutes a week of moderate-intensity physical activity to prevent further weight gain or to maintain the loss of a modest amount of weight. To achieve more-significant weight loss, you may need to exercise 300 minutes or more a week. You probably will need to gradually increase the amount you exercise as your endurance and fitness improve.
Keep moving. Even though regular aerobic exercise is the most efficient way to burn calories and shed excess weight, any extra movement helps burn calories. Making simple changes throughout your day can add up to big benefits. Park farther from store entrances, rev up your household chores, garden, get up and move around periodically, and wear a pedometer to track how many steps you actually take over the course of a day.
Behavior changes
A behavior modification program can help you make lifestyle changes and lose weight and keep it off. Steps to take include examining your current habits to find out what factors, stresses or situations may have contributed to your obesity.
Everyone is different and has different obstacles to managing weight, such as a lack of time to exercise or late-night eating. Tailor your behavior changes to address your individual concerns.
Behavior modification, sometimes called behavior therapy, can include:
Counseling. Therapy or interventions with trained mental health or other professionals can help you address emotional and behavioral issues related to eating. Therapy can help you understand why you overeat and learn healthy ways to cope with anxiety. You can also learn how to monitor your diet and activity, understand eating triggers, and cope with food cravings. Therapy can take place on both an individual and group basis. More-intensive programs — those that include 12 to 26 sessions a year — may be more helpful in achieving your weight-loss goals.
Support groups. You can find camaraderie and understanding in support groups where others share similar challenges with obesity. Check with your doctor, local hospitals or commercial weight-loss programs for support groups in your area, such as Weight Watchers.
Prescription weight-loss medication
Losing weight requires a healthy diet and regular exercise. But in certain situations, prescription weight-loss medication may help.
Keep in mind, though, that weight-loss medication is meant to be used along with diet, exercise and behavior changes, not instead of them. If you don't make these other changes in your life, medication is unlikely to work.
Your doctor may recommend weight-loss medication if other methods of weight loss haven't worked for you and you meet one of the following criteria:
Your body mass index (BMI) is 30 or greater
Your BMI is greater than 27, and you also have medical complications of obesity, such as diabetes, high blood pressure or sleep apnea
Before selecting a medication for you, your doctor will consider your health history, as well as possible side effects. Some weight-loss medications can't be used by women who are pregnant, or people who take certain medications or have chronic health conditions.
Commonly prescribed weight-loss medications include orlistat (Xenical), lorcaserin (Belviq), phentermine and topiramate (Qsymia), buproprion and naltrexone (Contrave), and liraglutide (Saxenda).
You will need close medical monitoring while taking a prescription weight-loss medication. Also, keep in mind that a weight-loss medication may not work for everyone, and the effects may wane over time. When you stop taking a weight-loss medication, you may regain much or all of the weight you lost.
Weight-loss surgery
In some cases, weight-loss surgery, also called bariatric surgery, is an option. Weight-loss surgery limits the amount of food you're able to comfortably eat or decreases the absorption of food and calories or both. While weight-loss surgery offers the best chance of losing the most weight, it can pose serious risks.
Weight-loss surgery for obesity may be considered if you have tried other methods to lose weight that haven't worked and:
You have extreme obesity (BMI of 40 or higher)
Your BMI is 35 to 39.9, and you also have a serious weight-related health problem, such as diabetes or high blood pressure
You're committed to making the lifestyle changes that are necessary for surgery to work
It doesn't guarantee that you'll lose all of your excess weight or that you'll keep it off long term. Weight-loss success after surgery depends on your commitment to making lifelong changes in your eating and exercise habits.
It doesn't guarantee that you'll lose all of your excess weight or that you'll keep it off long term. Weight-loss success after surgery depends on your commitment to making lifelong changes in your eating and exercise habits.
Common weight-loss surgeries include:
Gastric bypass surgery. In gastric bypass (Roux-en-Y gastric bypass), the surgeon creates a small pouch at the top of your stomach. The small intestine is then cut a short distance below the main stomach and connected to the new pouch. Food and liquid flow directly from the pouch into this part of the intestine, bypassing most of your stomach.
Laparoscopic adjustable gastric banding (LAGB). In this procedure, your stomach is separated into two pouches with an inflatable band. Pulling the band tight, like a belt, the surgeon creates a tiny channel between the two pouches. The band keeps the opening from expanding and is generally designed to stay in place permanently.
Biliopancreatic diversion with duodenal switch. This procedure begins with the surgeon removing a large part of the stomach. The surgeon leaves the valve that releases food to the small intestine and the first part of the small intestine (duodenum). Then the surgeon closes off the middle section of the intestine and attaches the last part directly to the duodenum. The separated section of the intestine is reattached to the end of the intestine to allow bile and digestive juices to flow into this part of the intestine.
Gastric sleeve. In this procedure, part of the stomach is removed, creating a smaller reservoir for food. It's a less complicated surgery than gastric bypass or biliopancreatic diversion with duodenal switch.
Other treatments
Vagal nerve blockade is another treatment for obesity. It involves implanting a device under the skin of the abdomen that sends intermittent electrical pulses to the abdominal vagus nerve, which tells the brain when the stomach feels empty or full. This new technology received FDA approval in 2014 for use by adults who have not been able to lose weight with a weight-loss program and who have a BMI of 35 to 45 with at least one obesity-related condition, such as type 2 diabetes.
Preventing weight regain after obesity treatment
Unfortunately, it's common to regain weight no matter what obesity treatment methods you try. If you take weight-loss medications, you'll probably regain weight when you stop taking them. You might even regain weight after weight-loss surgery if you continue to overeat or overindulge in high-calorie foods. But that doesn't mean your weight-loss efforts are futile.
One of the best ways to prevent regaining the weight you've lost is to get regular physical activity. Aim for 60 minutes a day.
Keep track of your physical activity if it helps you stay motivated and on course. As you lose weight and gain better health, talk to your doctor about what additional activities you might be able to do and, if appropriate, how to give your activity and exercise a boost.
You may always have to remain vigilant about your weight. Combining a healthier diet and more activity in a practical and sustainable manner are the best ways to keep the weight you lost off for the long term.
Take your weight loss and weight maintenance one day at a time and surround yourself with supportive resources to help ensure your success. Find a healthier way of living that you can stick with for the long term.
