Magazine article Clinical Psychiatry News

Diet, Exercise Must Accompany RX for Obesity: Atkins Diet Gains New Credibility. (Drug Treatment)

Magazine article Clinical Psychiatry News

Diet, Exercise Must Accompany RX for Obesity: Atkins Diet Gains New Credibility. (Drug Treatment)

Article excerpt

DENVER -- Weight-loss medications should never be prescribed for obese patients without also enrolling them in a program with behavioral modification and a dietary intervention, Dr. Samuel Klein said at an international conference of the Academy for Eating Disorders.

This triple-pronged approach is essential. Studies clearly show that the long-term weight loss achieved with orlistat or sibutramine alone--the only two drugs approved for long-term therapy--is rather modest. The cost and side effects of the medication remain the same regardless of whether the regimen also includes behavioral and dietary interventions, but the long-term weight loss is markedly enhanced with multimodal therapy.

In other words, although pharmacotherapy can be useful, the cornerstone of obesity treatment remains lifestyle changes, said Dr. Klein, the William H. Danforth Professor of Medicine and Nutritional Science at Washington University, St. Louis.

He provided these insights into the state of the art regarding these interventions:

* Physical activity. This is not a very effective means of reducing weight--the amount needed is just too great for most people--but in selected individuals who have achieved weight loss, exercise is an excellent way to help maintain it long term.

Recent studies show that after initial weight loss, an average of about 35 minutes daily of vigorous activity, such as aerobics or fast bicycling, or 80 minutes daily of moderate-intensity activity, such as brisk walking, is needed for long-term weight maintenance.

But these numbers are based entirely upon retrospective analyses of prospective data. "These are people who chose to be physically active during the follow-up period. That's very different than having a prospective randomized trial telling some people to exercise and others not to," Dr. Klein said. "In fact, when that's been done you don't see this great benefit of physical activity in maintaining long-term weight loss because people aren't very compliant with long-term physical activity when they're randomized to it."

Physical activity entails considerable effort to achieve a relatively small calorie deficit. For instance, a 125-pound patient who runs 3 miles in 30 minutes burns about 300 calories. A comparable calorie deficit can be obtained by reducing potato chip intake by 2 oz per day, or switching from two regular colas to two diet sodas. Many patients opt for the less-strenuous approach.

* Atkins diet. Dr. Klein was a co-investigator in a recently published year-long multi-center randomized prospective clinical trial in which 63 obese patients were assigned to the low-carbohydrate, high-fat, high-protein Atkins diet or a more conventional low-fat, high-carbohydrate diet such as that recommended by the American Heart Association and many other prevention-oriented groups.

This was a low-tech intervention: Participants were given a copy of an Atkins book or a manual on the low-fat diet, and then had casual follow-up on a monthly basis. There was no behavior modification program and no detailed dietitian advice.

Yet after 3 months, those on the Atkins diet had lost a mean of 14.7 pounds, compared with 5.8 pounds for the low-fat diet group. The difference in weight loss favoring the Atkins diet remained significant at 6 months. …

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