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C HAP TE R 38 / Obesity: An Overview of Assessment and Treatment 867

Goal of Treatment Dietary Therapy
During weight loss treatment, the strongest determinant of the
The goal of weight loss is not to achieve some cosmetic standard rate and amount of weight loss that will occur is the extent of the
of attractiveness, but rather to reduce morbidity and increase mo- negative energy balance. 58 A key component of dietary therapy is
bility and quality of life. The recommended initial weight loss a reduction in total caloric intake by 500 to 1,000 kcal/day, re-
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goal is 10%; however, improvement in obesity-related risk factors sulting in the patient consuming 800 to 1,500 kcal/day. This is re-
for CHD can be observed with as little as a 5% loss of initial ferred to as a low-calorie diet and has been shown to reduce
weight. If a weight loss of 10% is not maintained, reductions in weight by 8% over 6 months. A deficit of 500 kcal/day results in
total and LDL-cholesterol revert toward baseline. 7,53 The rate of a weight loss of 1 lb/week (1 lb is the equivalent of 3,500 kcal).
loss should be approximately 0.5 to 1 lb/week for the moderately Depending on the patient’s baseline weight and the amount of
obese and 1 to 2 lb/week in the severely obese. 54 weight loss desired, the patient may follow a diet ranging from
It is important to discuss treatment strategies and goals with 1,000 to 1,200 kcal for women and 1,200 to 1,800 kcal for
the patient because these have to be arrived at through mutual de- men. 55 Programs using the lifestyle approach include nutritional
cision making, and there could be a discrepancy between the education. 59 The focus of the instruction includes the energy
provider’s and the patient’s goals. 55 An example would be a 55- value of food (e.g., fat contains 9 cal/g compared to protein and
year-old woman who has lower body obesity and no additional carbohydrates, which contain 4 cal/g), how to read labels, the
risk factors but may wish to lose a certain amount of weight that three types of fat and the recommended distribution of these in
may be unrealistic. This patient may achieve the loss and feel bet- the diet, methods to reduce fat and increase fiber and complex
ter about her appearance, but if she is unable to sustain this loss, carbohydrate intake, and how to prepare food to reduce the addi-
she will regain and feel like a failure. This person may benefit from tion of calories. Patients also are instructed on recipe modification
guidance for a lower weight loss goal and exercise or a plan for sta- and ordering from a restaurant menu; some programs include
bility of current weight. However, if this same woman had central field trips to supermarkets to teach the participants how grocery
adiposity or presence of risk factors, she should be counseled for shopping should be done.
achieving a 10% weight reduction. Another scenario might in- An important component of dietary therapy is addressing both
volve an individual without additional risk factors, but a desire to fat and caloric restriction. In general, a 20% to 30% fat diet is rec-
achieve a body weight that is significantly below her current ommended and the patient is provided a daily fat gram goal along
weight and one she has not had since she was in her 20s. The with the calorie goal. The recommended diet composition is con-
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achievement and maintenance of this goal weight is unlikely, as sistent with the Adult Treatment Panel Step I Diet (Table 38-4).
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most individuals regain approximately one third of their lost Very-low-calorie diets, which are restricted to less than 800
weight in the year after treatment. A patient may benefit from an kcal/day, are no longer recommended for several reasons. They
initial goal of 5% to 10% reduction, and if this is achieved, an ad- provide inadequate nutrition unless supplemented, require med-
ditional goal can be established. ical supervision to monitor the patient’s nutritional and elec-
It is important for the provider to discuss with the patient what trolyte status, and increase the risk for development of gallstones.
his or her goals are for weight loss. A patient may think that im- Furthermore, studies have shown that the rapid weight loss is fol-
proved personal relationships or professional opportunities will re- lowed by a rapid regain. A recent meta-analysis reported that
sult from achieving the weight loss goal, but this is rarely the case long-term weight losses (average follow up was 1.9 years) were not
because more than just weight loss is usually necessary for such different from the low-calorie diet with a mean weight loss of
goals to be realized. The provider needs to emphasize to the pa- 6.3% 3.2% in the very-low-calorie diet groups compared with
tient the health benefits resulting from a 5% to 10% loss, and as- 5.0% 4.0% in the low-calorie diet groups. 61 The benefits of
sist the patient in being realistic about weight loss outcomes. 55–57 these weight loss plans do not outweigh the risks particularly
Once the patient and provider have agreed on the treatment ap- when long-term outcomes are considered.
proach and the initial goals, it is time to prepare the patient for the
course of treatment. Orienting the patient to the active participa-
tion required for successful weight loss facilitates cooperation and
adherence. Patients need to be instructed how to self-monitor food Table 38-4 ■ LOW-CALORIE STEP I DIET
and caloric intake and expenditure, which requires reading food la- Nutrient Recommended Intake
bels and at least initially, measuring food portions. Conveying un-
derstanding and support to the patient during the challenging Calories Approximately 500 to 1,000 kcal/day
course of weight loss and providing reinforcement for behavioral reduction from usual intake
change can go a long way in sustaining the person’s motivation. Total fat 30% of total calories
Saturated fatty acids 8% to 10% of total calories
Monounsaturated fatty acids Up to 15% of total calories
Polyunsaturated fatty acids Up to 10% of total calories
Components of the Treatment Cholesterol 300 mg/day
Protein Approximately 15% of total calories
Lifestyle Modification Carbohydrate 55% of total calories
Lifestyle therapy encompasses three principal components: nutri- Sodium chloride 100 mmol/day (approximately 2.4 g of
tional or dietary therapy, physical activity and daily activity, and sodium or 6 g of sodium chloride)
behavioral therapy. The changes in the patient’s dietary and activ- Calcium 1,000 to 1,500 mg/day
ity habits are facilitated and reinforced through the behavioral Fiber 20 to 30 g/day
strategies used in weight loss treatment. The following sections
From National Heart, Lung, and Blood Institute Expert Panel. (1998). Clinical guide-
describe the three components of standard lifestyle modification
lines on the identification, evaluation, and treatment of overweight and obesity in adults:
for weight control. The evidence report. Bethesda, MD: National Institutes of Health.