Dietary Interventions (Pharmacological Interventions) PDF

Dietary Interventions (pharmacological interventions) Pr. Roberta FORESTI Professor of Biochemistry, Faculty of Health, UPEC [email protected] Obesity treatment pyramid  Obesity and Overweight...

Dietary Interventions (pharmacological interventions) Pr. Roberta FORESTI Professor of Biochemistry, Faculty of Health, UPEC [email protected] Obesity treatment pyramid  Obesity and Overweight Prevention and treatment Diet and non-dietary approaches Diet with energy restriction Diet has to be adjusted to reduce energy intake - 1 kg of body weight = 7000 kcal - 0.5 kg/week weight loss requires 500 kcal/d deficit For class I obesity an energy deficit of 300-500 kcal/day is required For class III obesity an energy deficit of 500-1000 kcal/day is required Estimate of energy requirements in patients before starting the weight loss program (difficult! Consistent underreporting by patients) Tissue loss ~75% adipose ~25% lean Energy requirement to maintain weight after weight loss is less. A return to original baseline energy intake implies weight regain  Obesity – other options Behavior therapy – conditions of eating/shopping – triggers of uncontrolled eating Physical activity Drug therapy – appetite suppressants/other Non drug/ non diet – gastric bypass/stapling/banding  Why diets don’t work Body defends itself against weight loss Metabolic rate varies directly with body weight: losing weight causes thyroid hormone levels to drop and basal metabolic rate to slow down i.e. As feeding is reduced, the adipostat maintains fat stores at the pre-existing set point to conserve the limited reserves  Weight cycling Dieting to lose weight increases hunger as body attempts to maintain energy reserves as set point (strong willpower to lose weight) Feeding increases and weight gain is usually more than original weight lost (rebound) To avoid vicious cycling, stable weight reduction requires the ability to shift the set point To break the cycle, must overcome desire to eat and increase metabolic rate Reduce calorific intake and increase energy expenditure  Health benefits of modest weight loss A 5-10% weight loss in obese subjects can lead to: Decreased cardiovascular risk Decreased blood glucose and insulin levels Decreased blood pressure Decreased LDL and tryglycerides, increase in HDL Decrease in severity of sleep apnea Reduce symptoms of degenerative joint diseases Improvement in ginecological conditions Improvement in quality of life (appearance, self-esteem) Individuals in the weight-loss cohort had median 13% weight loss  Starvation diets Starvation (30 min/day, for at least 5 days each week). Clinical trials indicated that this results in an additional 1–1.5 kg weight loss over 12 months in addition to dietary intervention alone. Greater amount physical activity (30–45 min/day) is needed to prevent obesity and that for long-term weight maintenance in those who have lost weight, 60–90 min/day is required. As for diet, the challenge is to maintain a regular physical activity level  Benefits of regular physical activity Can promote weight loss in conjunction with reduced energy intake Improves cardiovascular and metabolic health Decreases loss of fat-free mass (muscle) associated with weight loss Improves maintenance of weight loss In general, it is encouraged to spend less time sitting. Even light-intensity activity can offset some of the risks of being sedentary  Pharmacological treatments in obesity Before prescribing medicines for the treatment of obesity, effective lifestyle support for weight loss should be provided during their use. In general, the medications work to reinforce the patient’s attempts to change eating behaviours and produce an energy deficit. Patients should be aware of side effects and treatment continuously monitored for effectiveness Pharmacological treatments in obesity  Pharmacological treatments in obesity Phentermine is an anorexic drug that inhibits appetite Orlistat is a pancreatic lipase inhibitor that blocks absorption of 30% of ingested fat when eating a 30% fat diet  Pharmacological treatments in obesity Liraglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist that is also used for the treatment of T2 diabetes. The exact mechanism of action for weight loss is not fully understood, but it appears to act on the parts of the brain that regulate appetite, increasing feeling of fullness and lowering feelings of hunger. Saxenda (liraglutide is the active priciple) is a medicine used along with diet and exercise to help manage weight in adults: who are obese (have a body-mass index – BMI – of 30 or more); who are overweight (have a BMI between 27 and 30) and have weight-related complications such as diabetes, abnormally high levels of fat in the blood, high blood pressure or obstructive sleep apnoea (frequent interruption of breathing during sleep). Double-blind trial involving 3731 patients who did not have T2D and who had a BMI of at least 30 or a BMI of at least 27 if they had treated or untreated dyslipidemia or hypertension  Pharmacological treatments in obesity About Wegovy® Wegovy® (once-weekly subcutaneous semaglutide 2.4 mg) is a GLP-1 receptor agonist indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with a BMI of 30 kg/m2 or greater (obesity), adults with a BMI of 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition, and pediatric patients aged 12 years and older with an initial BMI at the 95th percentile or greater for age and gender (obesity). Wegovy® is launched in the US, Denmark, Norway and Germany. Chao et al Trends in Cardiovascular Medicine, 2023 References 1. Wegovy® [package insert]. Plainsboro, NJ: Novo Nordisk Inc. 2. Wilding JPH, Batterham RL, Calanna S, et al. Once-weekly semaglutide in adults with overweight or obesity. N Engl J Med. 2021;384(11):989- 1002. 4. Garvey WT, Batterham RL, Bhatta M, et al. Two-year effects of semaglutide in adults with overweight or obesity: the STEP 5 trial. Nat Med. 2022;28(10):2083-2091.  Surgical procedures to treat obesity Bariatric surgery has rapidly become used as a treatment option for severe obesity, particularly since the advent of lower risk laparoscopic procedures. The most common types are: gastric band – a band is placed around the stomach, so you do not need to eat as much to feel full gastric bypass – the top part of the stomach is joined to the small intestine, so you feel fuller sooner and do not absorb as many calories from food sleeve gastrectomy – some of the stomach is removed, so you cannot eat as much as you could before and you'll feel full sooner  Effects of surgical procedures to treat obesity Weight loss surgery can achieve dramatic weight loss, but it's not a cure for obesity on its own. Patients need to commit to making permanent lifestyle changes after surgery to avoid putting weight back on. Including: change of diet – a liquid or soft food diet in the weeks after surgery, and gradually move onto a normal balanced that needs to be followed for life regular exercise – once recovered from surgery, patients are advised to start an exercise plan and continue it for life attend regular follow-up appointments to check how things are going after surgery and get advice or support if patients need it Women who have weight loss surgery will also usually need to avoid becoming pregnant during the first 12 to 18 months after surgery. Strong effects on diabetes, with striking and rapid improvements in glucose control.