Weight management refers to a set of practices and behaviors that are necessary to keep one’s weight at a healthful level. It is preferred to the term “dieting,” because it involves more than regulation of food intake or treatment of overweight people. People diagnosed with eating disorders that are not obese or overweight still need to practice weight management. Some healthcare professionals use the term “nutritional disorders” to cover all disorders related to weight.
The term “weight management” also reflects a change in thinking about treatment of obesity and overweight during the past 20 years. Before 1980, treatment of overweight people focused on weight loss, with the goal of helping the patient reach an ideal weight as defined by standard life insurance height-weight charts. In recent years, however, researchers have discovered that most of the negative health consequences of obesity are improved or controlled by a relatively modest weight loss, perhaps as little as 10% of the patient’s body weight. It is not necessary for the person to reach the ideal weight to benefit from weight management. Some nutritionists refer to this treatment goal as the “10% solution.” Second, the fact that most obese people who lose large amounts of weight from reduced-calorie diets regain it within five years has led nutrition experts to emphasize weight management rather than weight loss as an appropriate outcome of treatment.
Overweight and obese
Overweight and obese are not the same thing. People who are overweight weigh more than they should compared with set standards for their height. The excess weight may come from muscle tissue, body water, or bone, as well as from fat. A person who is obese has too much fat in comparison to other types of body tissue; hence, it is possible to be overweight without being obese.
Anorexia nervosa— An eating disorder marked by refusal to eat, intense fear of obesity, and distortions of body image.
Appetite suppressant— A medication given to reduce the desire to eat.
Bariatrics— The branch of medicine that deals with the prevention and treatment of obesity and related disorders.
Binge— A time-limited bout of excessive indulgence in eating; consuming a larger amount of food within a limited period of time than most people would eat in similar circumstances.
Binge eating disorder— An eating disorder in which the person binges but does not try to get rid of the food afterward by vomiting, using laxatives, or exercising.
Body mass index (BMI)— A measurement that has replaced weight as the preferred determinant of obesity. The BMI can be calculated (in American units) as 703.1 times a person’s weight in pounds divided by the square of the person’s height in inches.
Bulimia nervosa— An eating disorder marked by episodes of binge eating followed by purging, over-exercising, or other behaviors intended to prevent weight gain.
Ephedra— A herb used in traditional Chinese medicine to treat asthma and hay fever. It should never be used for weight management.
Hoodia— A succulent African plant resembling a cactus said to contain a natural appetite suppressant.
Obesity— Excessive weight gain due to accumulation of fat in the body, sometimes defined as a BMI of 30 or higher, or body weight greater than 30% above one’s desirable weight on standard height-weight tables.
Prevalence— The number of cases of a disease or disorder that are present in a given population at a specific time.
Sedentary— Characterized by inactivity and lack of exercise. A sedentary lifestyle is a major risk factor for becoming overweight or obese.
There are several ways to determine whether someone is obese. Some measures are based on the relationship between the person’s height and weight. The older measurements of this correlation are the so-called height-weight tables that list desirable weights for a given height. A more accurate measurement of obesity is body mass index, or BMI. The BMI is an indirect measurement of the amount of body fat. The BMI is calculated in American measurements by multiplying a person’s weight in pounds by 703.1, and dividing that number by the person’s height in inches squared. A BMI between 19 and 24 is considered normal; 25–29 is overweight; 30–34 is moderately obese; 35–39 is severely obese; and 40 or higher is defined as morbidly obese. More direct methods of measuring body fat include measuring the thickness of the skin fold at the back of the upper arm, and bioelectrical impedance analysis (BIA). Bioelectrical impedance analysis measures the total amount of water in the body using a special instrument that calculates the different degrees of resistance to an electrical current in different types of body tissue. Fatty tissue has a higher resistance to the current than body tissues containing larger amounts of water. A higher percentage of body water indicates a greater amount of lean tissue.
Eating disorders are a group of psychiatric disturbances defined by unhealthy eating or weight management practices. Anorexia nervosa is an eating disorder in which people restrict their food intake severely, refuse to maintain a normal body weight, and express intense fear of becoming obese. Bulimia nervosa is a disorder marked by episodes of binge eating followed by attempts to avoid weight gain from the food by abusing laxatives, forcing vomiting, or over-exercising. A third type, binge eating disorder, is found in some obese people, as well as in people of normal weight. In binge eating disorder, the person has an eating binge but does not try to get rid of the food after eating it. Although most patients diagnosed with anorexia or bulimia are women, 40% of patients with binge eating disorder are men.
The purpose of weight management is to help each patient achieve and stay at the best weight possible in the context of their overall health, occupation, and living situation. A second purpose is the prevention and treatment of diseases and disorders associated with obesity or with eating disorders. These disorders include depression and other psychiatric disturbances, in addition to the physical problems associated with nutritional disorders.
Obesity has become a major public health concern in the United States in the last decade. As of 2007, obesity ranks second only to smoking as a major cause of preventable deaths. It is estimated that 300,000 people die in the United States each year from weight-related causes. The proportion of overweight adults in the general population has continued to rise since the 1960s. According to the National Health and Nutrition Examination Survey (NHANES) of 2004, almost two-thirds of American adults are overweight, and almost a third is obese. In addition, there has been a 42% increase in the rate of childhood obesity since 1980.
The prevalence of obesity in the United States varies somewhat according to sex, age, race, and socioeconomic status. Among adults, 35% of women are considered obese, compared to 31% of men. The rate of obesity increases as people get older; those aged 55 or older are more than twice as likely to be obese as those in their 20s. African American men have the same rate of obesity as Caucasian men; however, African American women are almost twice as likely as Caucasian women to be obese by the time they reach middle age. The same ratio holds true for socioeconomic status; people in the lowest third of the income and educational level distribution are twice as likely to be obese as those with more education and higher income.
From the economic standpoint, obesity costs the United States more than $117 billion each year. This amount includes the direct costs of hospital care and medical services, which come to $61 billion annually, or 7% of all healthcare costs. Another $56 billion represents the indirect costs of obesity, such as disabilities related to overweight or work days lost to obesity-related illnesses.
Obesity is considered responsible for:
- 88-97% of cases of type 2 diabetes
- 57-70% of cases of coronary heart disease
- 70% of gallstone attacks
- 35% of cases of hypertension
- 11% of breast cancers
- 10% of colon cancers
In addition, obesity intensifies the pain of osteoarthritis and gout; increases the risk of complications in pregnancy and childbirth; contributes to depression and other mental disorders; and makes a person poor candidate for surgery. Many surgeons refuse to operate on patients who weigh more than 300 lb (136 kg).
Although fewer people suffer from eating disorders than from obesity, the National Institutes of Mental Health (NIMH) reports that 10 million adults in the United States meet the diagnostic criteria for anorexia or bulimia. Although eating disorders are stereotyped as affecting only adolescent or college-aged women, as of 2007 at least 10% of people with eating disorders are males—and the proportion of males to females is rising. Moreover, the number of women over 45 years of age who are diagnosed with eating disorders is also rising; many doctors attribute this startling new trend to fear of aging, as well as fear of obesity.
The long-term health consequences of eating disorders include gum disease and loss of teeth, irregular heart rhythm, disturbances in the chemical balance of the blood, and damage to the digestive tract. At least 50,000 people die each year in the United States as the direct result of an eating disorder; anorexia is the leading cause of death in women between the ages of 17 and 25.
To understand the goals and structure of nutritionally sound weight management programs, it is helpful to look first as the causes of being overweight, obesity, and eating disorders.
Causes of nutrition-related disorders
GENETIC/BIOLOGIC. Studies of twins separated at birth and research with genetically altered mice have shown that there is a genetic component to obesity. Some researchers think that there are also genetic factors involved in eating disorders.
LIFESTYLE-RELATED. The ready availability of relatively inexpensive, but high-caloric snacks and “junk food” is considered to contribute to the high rates of obesity in developed countries. In addition, the fast pace of modern life encourages people to select quick-cooking processed foods that are high in calories, rather than making meals that are more healthful but take longer to prepare. Lastly, changes in technology and transportation patterns mean that people today do not do as much walking or hard physical labor as earlier generations did. This sedentary or inactive lifestyle makes it easier for people to gain weight.
SOCIOCULTURAL. In recent years, many researchers have examined the role of advertising and the mass media in encouraging unhealthy eating patterns. On the one hand, advertisements for such items as fast food, soft drinks, and ice cream often convey the message that food can be used to relieve stress, reward, or comfort oneself, or substitute for a fulfilling human relationship. On the other hand, the media also portray unrealistic images of human physical perfection. Their emphasis on slenderness as essential to beauty, particularly in women, is often cited as a major factor in the increase of eating disorders over the past three decades.
Another sociocultural factor that contributes to obesity among some Hispanic and Asian groups is the belief that children are not healthy unless they look plump. Overfeeding in infancy and early childhood, unfortunately, makes weight management in adolescence and adult life much more difficult.
MEDICATIONS. Recent research has found that a number of prescription medications can contribute to weight gain. These drugs include steroid hormones, antidepressants, benzodiazepine tranquilizers, lithium, and antipsychotic medications.
Aspects of weight management
Since the late 1980s, nutritionists and healthcare professionals had come to recognize that successful weight management programs have three characteristics, including:
- They present weight management as a lifetime commitment to healthful patterns of eating and exercise, rather than emphasize strict dieting alternating with carelessness about eating habits.
- They are tailored to each person’s age, general health, living situation, and other individual characteristics.
- They recognize that the emotional, psychological, and spiritual dimensions of human life are as important to maintaining a healthy lifestyle as the medical and nutritional facets.
NUTRITION. The nutritional aspect of weight management programs includes education about healthful eating, as well as modifying the person’s food intake.
DIETARY REGULATION. Most weight-management programs are based on a diet that supplies enough vitamins and minerals; 50-63 grams of protein each day; an adequate intake of carbohydrates (100 g) and dietary fiber (20–30 g); and no more than 30% of each day’s calories from fat. Good weight-management diets are intended to teach people how to make wise food choices and to encourage gradual weight loss Some diets are based on fixed menus, while others are based on food exchanges. In a food-exchange diet, a person can choose among several items within a particular food group when following a menu plan. For example, if a person’s menu plan allows for two items from the vegetable group at lunch, they can have one raw and one cooked vegetable, or one serving of vegetable juice along with another vegetable.
NUTRITIONAL EDUCATION. Nutritional counseling is important to successful weight management because many people, particularly those with eating disorders, do not understand how the body uses food. They may also be trying to manage their weight in unhealthy ways. One recent study of adolescents found that 32% of the females and 17% of the males were using such potentially dangerous methods of weight control as smoking, fasting, over-the-counter (OTC) diet pills, or laxatives.
Regular physical exercise is a major part of weight management because it increases the number of calories used by the body and because it helps the body to replace fat with lean muscle tissue. Exercise also serves to lower emotional stress levels and to romote a general sense of well-being. People should consult a doctor before beginning an exercise program, however, to make sure that the activity that interests them is safe relative to any other health problems they may have. For example, people with osteo-arthritis should avoid high-impact sports that are hard on the knee and ankle joints. Good choices for most people include swimming, walking, cycling, and yoga or other stretching exercises.
Both obesity and eating disorders are associated with a variety of psychiatric disorders, most commonly major depression and substance abuse. Almost all obese people feel harshly judged and criticized by others, and fear of obesity is a major factor in the development of both anorexia and bulimia. Many people find medications and/or psychotherapy to be a helpful part of a weight management program.
MEDICATIONS. In recent years, doctors have been cautious about prescribing appetite suppressants, which are drugs given to reduce the desire for food. In 1997, the Food and Drug Administration (FDA) banned the sale of two drugs: fenfluramine and phen-termine (known as “fen-phen”) when they were discovered to cause damage to heart valves. A newer appetite suppressant, known as sibutramine (Meri-dia), was approved as safe in 1997. The drug is being monitored by the FDA as of 2007, however, because of reports linking it to heart failure, kidney failure, and stomach problems. Another new drug that is sometimes prescribed for weight management is called orli-stat (Xenical). It works by lowering the amount of dietary fat that is absorbed by the body. However, it can cause significant diarrhea or intestinal gas.
People with eating disorders are sometimes given antidepressant medications, most often fluoxetine (Prozac) or venlafaxine, to relieve the symptoms of depression or anxiety that often accompany eating disorders.
COGNITIVE-BEHAVIORAL THERAPY. Cognitive-behavioral therapy (CBT) is a form of psychotherapy that has been shown to be effective in reinforcing the changes in food selection and eating patterns that are necessary to successful weight management. In this form of therapy, usually offered in specialized clinics, patients learn to modify their eating habits by keeping diaries and records of what they eat, what events or feelings trigger overeating, and any other patterns that they notice about their choice of foods or eating habits. They also examine their attitudes toward food and weight management, and work to change any attitudes that are self-defeating or interfere with a healthy lifestyle. Most CBT programs also include nutritional education and counseling. As of 2007, however, some researchers maintain that more work needs to be done on the use of CBT in real-world settings, not just university-related specialized clinics.
WEIGHT-MANAGEMENT GROUPS. Many doctors and nutritional counselors suggest that patients attend a weight-management group for social support. Social support is essential in weight management, because many who suffer from obesity or an eating disorder struggle with intense feelings of shame. Many isolate themselves from others because they are afraid of being teased or criticized for their appearance. Such groups as Overeaters Anonymous (OA) or Take Off Pounds Sensibly (TOPS) help members in several ways: They help to reduce the levels of shame and anxiety that most members feel; they teach strategies for coping with setbacks in weight management; they provide settings for making new friends; and they help people learn to handle problems in their workplace or in relationships with family members.
ANTI-DISCRIMINATION GROUPS. Another approach to weight-related psychological issues is tackling public discrimination against overweight people, including educational and employment discrimination as well as verbal harassment and teasing. The two major groups in the United States are the Council on Size and Weight Discrimination (CSWD) and the National Association to Advance Fat Acceptance (NAAFA). The CWSD describes itself as “a not-for-profit group which works to change people’s attitudes about weight. We act as consumer advocates for larger people, especially in the areas of medical treatment, job discrimination, and media images.” NAAFA states its goals as “eliminat[ing] discrimination based on body size and provid[ing] fat people with the tools for self-empowerment through public education, advocacy, and member support.”
As of 2007, bariatric surgery is the most successful approach to weight management for people who are morbidly obese (BMI of 40 or greater), or severely obese with additional health complications. Surgical treatment of obesity usually results in a large weight loss that is successfully maintained for longer than five years. The most common surgical procedures for weight management are vertical banded gastroplasty (VBG), sometimes referred to as “stomach stapling,” and gastric bypass. Vertical banded gastroplasty works by limiting the amount of food the stomach can hold, while gastric bypass works by preventing normal absorption of the nutrients in the food.
Complementary and alternative medicine (CAM) approaches
Some forms of complementary and alternative medicine are beneficial additions to weight management programs.
MOVEMENT THERAPIES. Movement therapies include a number of forms of exercise, such as tai chi, yoga, dance therapy, Trager work, and the Feldenkrais method. Many of these approaches help people improve their posture and move their bodies more easily as well as keeping active. Tai chi and yoga, for example, are good for people who must avoid high-impact physical workouts. Yoga can also be adapted to a person’s individual needs or limitations with the help of a qualified teacher following a doctor’s recommendations. Books and videos on yoga and weight management are available through most bookstores or the American Yoga Association.
SPIRITUAL AND RELIGIOUS PRACTICE. Prayer, meditation, and regular religious worship have been linked to reduced emotional stress in people struggling with weight issues. In addition, many people find that spiritual practice helps them to keep a healthy perspective on weight management, so that it does not crowd out other important interests and concerns in their lives.
HERBAL PREPARATIONS. The one type of alternative treatment that people should be extremely cautious about making part of a weight management program is over-the-counter herbal preparations advertised as “fat burners,” muscle builders, or appetite suppressants. Within a two-week period in early 2003, the national media carried accounts of death or serious illness from taking these substances. One is ephedra, an herb used in traditional Chinese medicine that can cause strokes, heart attacks, seizures, and psychotic episodes. The other is usnic acid, a compound derived from lichens that can cause liver damage.
Another herbal preparation that has received considerable media attention since 2004 is hoodia (Hoodia gordonii), a succulent plant similar to a cactus that is native to South Africa and Namibia. Used for generations by the native inhabitants of these parts of Africa to treat indigestion, hoodia was studied by several pharmaceutical companies in the early 2000s as a natural appetite suppressant. In 2002, one such company stopped its research into hoodia on the grounds that it has potentially severe side effects on the liver. Nonetheless, hoodia has been featured on such popular television shows as 60 Minutes, and is marketed as of 2007 in tablets, shakes, teas, and other diet products. As of 2007, however, there is no scientific evidence that hoodia is effective in curbing appetite, and is not recommended by any professional medical or nutrition society.
As of 2007, much more research needs to be done to improve the success of weight management programs. A position paper published by the American Dietetic Association in the summer of 2002 summarizes the present situation: “Although our knowledge base has greatly expanded regarding the complex causation of increased body fat, little progress has been made in long-term maintenance interventions, with the exception of surgery.” A study published in the Journal of the American Medical Association in 2003 showed that neither subjects randomly assigned to a commercial weight loss program nor those assigned to a self-help weight loss program lost more than a modest amount of weight and succeeded in keeping it off over a two-year period. Most adults in weight maintenance programs find it difficult to change eating patterns learned over a lifetime. Furthermore, their efforts are all too often undermined by friends or relatives, as well as by media messages that encourage overeating or the use of food as a mood-enhancing drug. More effective weight maintenance programs may well depend on broad-based changes in society.
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Rebecca Frey, PhD