What is it?

Overview

What Is It?
Obesity is a complex disorder. It is caused by multiple factors, both environmental and inherited, including excessive calorie and food intake, decreased physical activity and genetic influences.

America has become a nation of chronically overweight people. Today approximately 66.3 percent of American adults are either overweight or obese, and 32 percent are obese, according to the National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of the U.S. population. Between 1994 and 2004, the percentage of Americans who met the criteria for being overweight rose from 56 to 66 percent, and the percentage who met the criteria for obesity rose from 23 to 32 percent. Moreover, the Centers for Disease Control and Prevention (CDC) reports that 32 percent of Americans are obese. Why are these facts alarming?

Obesity, along with unhealthy dietary habits and lifestyles that don't include much or any physical activity, is the second leading cause of preventable death in the United States and results in an estimated $117 billion in health care costs each year. Overweight people are more likely to have high blood pressure and high blood cholesterol, major risk factors for heart disease and stroke. Additionally, the results of a large study supported by the U.S. National Heart, Lung, and Blood Institute (NHLBI) suggest that excess body weight is strongly and independently associated with an increased risk of heart failure.

As people become overweight, their glucose tolerance declines, putting them at twice the risk for developing type 2 diabetes. Diabetes is a major cause of early death, heart disease, kidney disease, stroke, blindness and amputation. Several types of cancer are associated with being overweight, including cancer of the uterus, gallbladder, kidney, breast and colon. Other conditions linked with obesity include sleep apnea, osteoarthritis, gout, gallbladder disease and infertility. Obesity-related conditions worsen as weight increases and often improve as the excess weight is lost.

Obesity is a major component of a group of metabolic risk factors known collectively as metabolic syndrome, including:

• Central obesity (too much fat tissue in and around the abdomen)
• Elevated fasting glucose equal to or greater than 100 mg/dL
• High triglycerides (equal to or greater than 150 mg/dL) and low HDL cholesterol (less than 40 mg/dL for men or less than 50 mg/dL for women), which are both associated with plaque accumulation in the arteries
• High blood pressure (130/85 mm HG or higher)
• Insulin resistance or glucose intolerance
• Other proinflammatory and prothrombotic states

Health conditions that promote metabolic syndrome are overweight/obesity, physical inactivity and genetic factors. People who have this syndrome are at increased risk for developing coronary heart disease, stroke, peripheral arterial disease and type 2 diabetes.

Obesity is a complex disorder. It is caused by multiple factors, both environmental and inherited, including excessive calorie and food intake, decreased physical activity and genetic influences. The formula for weight gain is fairly straightforward, however. You gain weight when you consume more calories (energy) than your body uses or needs.

What's the difference between being obese and being overweight? The defining characteristic in both overweight and obese people is excess body fat. The difference is a matter of degree.

Health care professionals use a simple calculation called the body mass index (BMI) to determine body weight relative to height. In adults, the BMI calculation strongly correlates with total body fat content in adults. Overweight is defined as having a body mass index (BMI) between 25 and 29.9. Obesity is defined as having a BMI of 30 or more.

Where excess body fat is distributed on your body also plays a role in your risk for disease. Weight gain around your waist (specifically in your abdominal area) is more of a health risk than weight gained on your hips and thighs. Unlike fat around the thighs, which is more common in women and is more likely to serve as an energy reservoir, abdominal fat deposits fatty acids directly into the bloodstream for immediate short-term energy, increasing triglyceride and, eventually, cholesterol levels. Therefore, excess abdominal fat is associated with an increase in blood cholesterol and insulin resistance, which may result in diabetes. An "apple shaped" figure may also raise your risks for other life-threatening illnesses, such as heart disease and stroke.

Diagnosis

Diagnosis

An excess of body fat-the defining characteristic of obesity-results from an imbalance between the amount of calories you take in and those you expend. The reasons for this imbalance are unclear, and the relationship between energy intake/expenditure and body fat storage and distribution varies from person to person. Factors that promote obesity include:

• genetic predisposition

• family history of obesity

• age

• behavioral factors (including a high-fat or high-calorie diet and sedentary lifestyle)

Measuring Obesity

Assessing your weight to determine if you are obese involves two key measurements-body mass index (BMI) and waist circumference. Understanding your risk factors for conditions associated with obesity, according to clinical practice guidelines issued by the National Heart, Lung, and Blood Institute (NHLBI), is important. First, your health care professional should determine your body mass index (BMI), which describes your body weight relative to your height. It is strongly correlated with total body fat content in adults. Your BMI is your weight in pounds divided by your height in inches squared, then multiplied by 703. The following chart shows body mass indices for people of various heights and weights. To determine your BMI, find the row that most closely approximates your weight. Read across the row until it crosses the column closest to your height.

A woman or man with a BMI between 25 and 29.9 is considered overweight; 30 or more is considered obese; and 40 or greater is considered extreme obesity. Women in the highest obesity category have a significantly higher risk of hypertension and/or high blood cholesterol than women of normal weight.

Charts that use the same mathematical principles as the BMI can provide figures for your ideal weight based on your height. For example, a height-weight chart that shows lower and upper limits of overweight, obese and extreme obesity can be found at multiple Web sites. For more information on calculating your BMI and how to achieve and maintain a healthy weight, visit the National Heart, Lung and Blood Institute's Aim for a Healthy Weight Obesity Education Initiative.

• In addition to comparing your weight to a chart of established acceptable weight ranges, your health care professional can actually measure your body composition—the most accurate assessment technique because it differentiates between weight that is attributable to fat accumulation and weight that represents muscle development. Women with more than 30 percent body fat (25 percent for men) are considered obese. However, it is difficult to measure body fat precisely. The most accurate method has been to weigh a person underwater, but this procedure is limited to laboratories with special equipment. Your health care professional is more likely to conduct one or more of these tests:

  • Measuring skin-fold thickness and subcutaneous fat, which lie just under the skin, at targeted areas. Areas include the back of your upper arm, waist or thigh. The health care professional uses calipers, an instrument that looks like tongs. Measurements of skin-fold thickness depend on the skill of the examiner and may vary widely

  • Bioelectrical impedance analysis (BIA). There are two forms of BIA. With one form, the patient stands on a special scale with footpads and a harmless amount of electrical current is sent through her body to calculate the percentage body fat. The second type of BIA involves the use of a portable instrument called an impedance analyzer to transmit a noninvasive, low frequency electrical current through electrodes placed on the patient's hand and foot with a gel. The change in voltage between electrodes is measured, and the patient's body fat percentage is calculated.

  • Waist circumference. Unlike fat around the thighs, which is more common in women and is more likely to serve as an energy reservoir, abdominal fat delivers fatty acids directly into the bloodstream for immediate short-term energy, increasing triglyceride and, eventually, cholesterol levels. Health care professionals aren't certain why this proves detrimental to your health, but higher proportions of abdominal fat are associated with higher risks of insulin resistance, diabetes, high blood pressure and cardiovascular disease (heart disease and stroke).

How can you estimate your body fat distribution? Look at yourself in the mirror. If you are more apple-shaped than pear-shaped, you probably have visceral fat accumulation. Women with a waist circumference over 35 inches (and men over 40 inches) are at greater risk.

Your health care professional also should ask you about or conduct tests to determine other risk factors for disease and conditions associated with obesity. This includes:

• Taking a personal weight history

• Determining your waist-to-hip ratio. Divide your waist measurement by your hip measurement (the widest part of your behind). Ideally, women should have a waist-to-hip ratio of 0.8 or less.

• Asking if you have relatives with illnesses related to being overweight, such as type 2 diabetes mellitus or heart disease

• Discussion of weight-loss methods used in the past

• Taking your blood pressure and conducting blood tests

It is important to tell your health care professional about any medical or health conditions you have and any medications, vitamins, minerals, herbs or nutritional supplements you're taking. Also let your health care professional know if you are pregnant or breast-feeding or if you're planning on surgery that requires general anesthesia.

The types of health care professionals you might consult to diagnose and treat obesity include:

• A nutritionist. There is no accepted national definition for the title "nutritionist." Some states have a statutory definition of nutritionist stating that the RD credential is not required for certification as a nutritionist but is required for licensing as a dietitian. In general, the license or certification as a dietitian can be obtained with a bachelor's degree and a related supervised practice experience component (or proof of RD status with the Commission on Dietetic Registration), while the nutritionist licensure or certification typically requires a master's degree or higher.

  Make sure any nutritionist you see is licensed by a state agency. Nutritionists, with educational background in foods and nutrition, and dietitians evaluate the diets and nutritional habits of clients and help structure more healthful eating patterns and weight-management strategies based on their patients' health needs, food selection and calorie goals. Nutritionists usually do not advise patients with chronic illnesses, disorders and other disease conditions.

• A registered dietitian (RD). An RD is a dietitian who has completed academic and practice requirements established by the American Dietetic Association. These include a bachelor's degree, an accredited preprofessional experience program, successful completion of a national credentialing exam and ongoing continuing professional development. Many RDs also have a master's degree and advanced training in a nutrition subspecialty, such as diabetes.

• An endocrinologist. Endocrinology is the field of medicine involving the body's chemical messengers, or hormones, and its biochemical control mechanisms, or metabolism. Endocrinologists are physicians who care for patients with complex hormonal disorders and metabolic conditions, including obesity, diabetes, thyroid disorders, metabolic bone disease, pituitary and adrenal conditions, and growth and gonadal disorders.

Treatment

Treatment

Losing as little as five to 10 percent of your body weight and maintaining that loss can significantly improve your health by increasing glucose tolerance and lowering blood pressure and cholesterol levels. Thus, if you're overweight or obese, you may need to seek medical help to lose weight as well as to maintain it.

Experts recommend losing no more than one to two pounds per week. Maintaining weight loss can be more difficult than losing the weight to begin with, so long-term lifestyle change is key.

The National Weight Control Registry is a self-selected group of over 5,000individuals who have lost at least 30 pounds and maintained the weight loss for more than a year. The individuals who are listed in the registry have reported the following:

• 90 percent exercise, on average, about 60 minutes per day.

• 45 percent of registry participants lost the weight on their own, and the other 55 percent lost weight with the help of some type of program.

• 78 percent eat breakfast every day.

• 62 percent watch less than 10 hours of TV per week.

• NWCR members kept the weight off in various ways. Most report continuing to maintain a low-calorie, low-fat diet and engaging in high levels of activity.

The good news is that burning off more calories than you're taking in will cause you to lose weight. The bad news is that there's no magic formula. Studies find that if you lose the weight slowly, you'll be much more effective at keeping it off, especially if you incorporate exercise into your routine and reduce other sedentary behavior, such as watching TV.

The safest way to lose weight is to eat a nutritionally complete diet that is moderate in calories and fat, add exercise to your daily routine and decrease sedentary activities. In some cases, for example, if your health is being immediately and severely compromised because of your weight, faster weight loss may be appropriate. In these cases, your health care professional may recommend drug therapy orsurgery.

Changing Your Diet

The first element of treatment is changing your diet. Your health care professional should provide detailed guidance on the number and types of calories you should eat. As a rule of thumb, however, if you take in about 250 calories per day less than is needed to maintain your current weight, combined with an exercise regime that burns an additional 250 calories a day, you'll lose about a pound a week.

The number of calories your body needs to maintain its basic functions such as breathing and digestion is known as your basal metabolic rate. Several factors go into the calculation of your BMR, including your age, height, weight and gender. To get an idea of your BMR, go to http://www.bmi-calculator.net/bmr-calculator.

It's difficult to determine exactly how many calories you need to maintain your weight at your current level of physical activity. One way to estimate your BMR is to keep a detailed food diary over the course of a few days to a week during which you maintain your weight. Determine exactly how many calories you eat on an average day (several books and Web sites provide calorie counts for thousands of foods) and use that figure as a starting place from which you then subtract 250 calories.

After you've determined how many calories a day you should eat, you need to plan daily menus. A dietitian or nutritionist can help you plan menus that include the types and amounts of food you should eat, which, in most cases, should be based on guidelines developed by the federal government in its Dietary Guidelines for Americans. The guidelines emphasize calorie reduction as well as balance, moderation and variety in food choices, with an emphasis on whole-grain products, vegetables and fruits.

To satisfy basic nutritional needs, eat a variety of foods including low-fat dairy, healthy protein sources like chicken, fish, eggs and soy products, vegetables and whole grains, and allow for an occasional treat. While you should try to cut back on excess fats and sugars, all foods and beverages can be consumed in moderation. As soon as you label a food as "off limits," chances are you will crave and perhaps even binge on it.

The 2005 Dietary Guidelines recommend the following (based on a 2,000 calorie-per-day diet). To find the amounts that are right for you, visit the Food Pyramid Web site):

Meat and beans (protein)

• Eat five-and-a-half ounces of protein every day (vary your choices of meats, poultry, fish, beans, peas, nuts and seeds).

Fruits, vegetables and milk

• Eat two cups a day of fruit and two-and-a-half cups a day of vegetables.

• Eat a variety of fruits and vegetables every day and choose from all of the five vegetable subgroups (dark green, orange, legumes, starchy vegetables and other vegetables) several times per week. You may consume fresh, frozen, canned or dried; go light on fruit juices.

• Drink three cups per day of either fat-free or low-fat milk or eat equivalent milk products such as yogurt and cheese.

Carbohydrates

• Eat six ounces of grains (cereal, breads, crackers, rice or pasta) a day. At least three ounces should be whole grain, and the other three enriched or whole grain. One ounce equals about one slice of bread, one cup of cereal or one-half cup of cooked rice, cereal or pasta.

• Eat fruits and vegetables that are high in fiber and choose whole grains.

• Try to avoid adding sugar or sweeteners to foods and beverages.

Sodium and potassium

• Do not consume more than 2,300 mg of sodium (approximately 1 teaspoon of salt) per day.

• Use little or no salt when preparing foods.

• Eat fruits and vegetables high in potassium such as potatoes, sweet potatoes, soybeans, bananas and spinach.

Balanced food plans encourage making wise choices about everyday foods so you can maintain a healthy weight throughout your lifetime. Many popular diet plans, however, such as the high-protein/low-carbohydrate diet, don't include balanced choices. While women can lose weight on these diets, they may find themselves dangerously deficient in certain nutrients or food groups and dangerously high in others. In most cases, women who go on these diets tend to regain any lost weight when the diet ends. That's because these diets don't help you change your lifestyle and your way of handling food and temptation in the long run.

Most successful weight-loss plans call for a reduction in both calories and fat, although fat is probably not a critical component in obesity. Instead, overall calories and lack of physical activity, coupled with a sedentary lifestyle, are most important.

Still, health care professional and dietary guidelines recommend women moderate their fat consumption to 20 to 35 percent or less of total calorie intake, with saturated fats accounting for less than 10 percent and the rest comprised of equal amounts of monounsaturated fat and polyunsaturated fats. These fats come from vegetable, not animal, sources.

Also, reduce your cholesterol intake to less than 300 mg per day. Strategies for reducing saturated fat and cholesterol include:

• Only eat three servings or less per week of red meats, processed meats, organ meats, eggs and high-fat dairy products.

• Choose low saturated-fat protein sources, such as fish, turkey, chicken, legumes (dried peas and beans), nuts and seeds.

• Use lean cuts of meat and trim excess fat.

• Substitute skim and low-fat milk for high-fat dairy foods.

• Broil, bake or boil foods instead of frying.

• Increase your consumption of fruits, vegetables and whole grains.

In addition to low-fat dietary approaches, some large studies also point to the Mediterranean-style diet as an alternative pattern of eating to reduce your risk of heart disease. Like the low-fat diets, the Mediterranean eating pattern focuses on fruits, vegetables, whole grains, nuts and seeds, but it also includes olive oil as a significant source of monounsaturated fat and wine in low to moderate amounts. The major protein sources are dairy, fish and poultry, with minimal red meat.

The Mediterranean eating style allows a higher percentage of calories from fat than the low-fat diets typically endorsed by health organizations, but several recent major studies have shown that the diet is an alternative to low-fat diets, especially for lowering risk of diabetes and heart attacks, often related to weight.

Increasing Physical Activity

The second element to losing weight and maintaining a healthy weight is adding exercise to your daily routine and reducing the time you spend sitting. Exercise not only burns calories, it also tempers your appetite, boosts metabolism, improves sleep and provides psychological benefits, such as stress reduction and an increased feeling of control and self-esteem.

If you are over 40, have been inactive for some time, suffer from shortness of breath or weakness that interferes with daily activities or have a chronic health condition, consult a health care professional before increasing your physical activity. Notify your health care professional about any chest pain, faintness or dizziness, bone or joint pain you're experiencing, and any medications you're taking.

Physical activity is defined as any bodily movement produced by skeletal muscles resulting in energy expenditure. The best kinds of exercises for burning calories are moderate- to vigorous-intensity physical activities. The calories burned per hour are listed for a 140-pound healthy woman.

Moderate intensity activities include:

• hiking (386 calories)

• light gardening/yard work (302 calories)

• dancing (319 calories)

• golf, walking and carrying the clubs (244 calories)

• bicycling, less than 10mph (370 calories)

• walking, 3.5 mph (370 calories)

• yoga (336 calories)

Vigorous intensity physical activities include:

• aerobics, high-impact (445 calories)

• calisthenics (512 calories)

• running/jogging, 5 mph (580 calories)

• swimming (580 calories)

• bicycling, 12 to 14 mph (554 calories)

• racquetball, casual (445 calories)

• skiing, downhill (554 calories)

• weight lifting, vigorous (400 calories)

While you and your health care professional should set up a detailed exercise plan based on your individual health status, the 2005 Dietary Guidelines recommend healthy women who want to manage body weight and prevent gradual unhealthy weight gain engage in 60 minutes of moderate-to-vigorous aerobic exercise on most or all days of the week while not exceeding caloric intake requirements.

You don't have to do 60 minutes at once; thirty minutes of an aerobics video in the morning and 30 minutes of brisk walking in the evening works just as well as walking for an hour straight. Remember: the longer and more vigorously you work out in a day, the greater the health benefit.

The best way to keep weight off once it's been lost is with 60 to 90 minutes of moderate-intensity exercise per day, being careful not to exceed your specific daily calorie requirement.

If you have been inactive, you need to work up slowly to this amount so you don't get injured or overly fatigued and become discouraged. Start with five or 10 minutes (or whatever you're comfortable with) every other day, adding one minute every other session. Low- to moderate-intensity exercise, like housework, gardening and walking the dog, provide a great deal of general health benefits, but for weight loss, you need to up the ante and exercise at a higher intensity with more vigorous activities like brisk walking or jogging, singles tennis or other racquet sports, aerobics classes, ice or roller skating, swimming or cycling.

Because the goal of moderate to vigorous exercise is to work your heart muscle, your exercise needs to increase your heart rate. One way to determine if you are exercising intensely enough is to measure your heart rate. After warming up and then sustaining an aerobic activity for about five to 10 minutes, take your pulse within five seconds of stopping by placing two fingers on the carotid artery on the side of your neck, just under your jaw line and about one to two inches in front of your ear. Count the beats for 10 seconds.

Your heart rate should be about 50 to 85 percent of its maximum. (You can calculate your maximum heart rate by subtracting your age from 220).

If you're out of shape or older than 60, aim for an intensity at the lower end of the 50 to 85 percent range. To determine what your heart rate should be during exercise, subtract your age from 220; divide that number by six for a 10-second heart rate count, then multiply that number by 0.5 for the lower end of the range and 0.85 for the higher end. For example, if you're 70:

• 220 - 70 = 150 (this would be your maximum heart rate for one minute)

• 150 / 6 = 25 (this would be your maximum heart rate for 10 seconds)

• 25 x 0.50 = 12.5 (this would be 50 percent of your maximum, or the lower end of where your 10-second heart rate should be when you're exercising)

• 25 x 0.85 = 21.25 (this would be 85 percent of your maximum, or the higher end of where your 10-second heart rate should be when you're exercising).

The following chart illustrates recommended 10-second heart rate counts; the number of beats you count should fall between the two numbers listed beside your age.

An easier way to judge intensity is the "talk test." You shouldn't be exercising so hard that you can't talk with a friend or recite a poem. If you can't talk without gasping for breath, slow down. On the other hand, if your exercise is easy enough that you can sing a song out loud, you probably need to increase your intensity.

Another type of exercise has received much attention over the past several years for its contribution to weight loss efforts. Strength training, which includes weight lifting and isometrics, or using your own body weight as resistance, not only improves muscular strength and endurance but raises metabolism, enabling you to burn more calories.

Make sure you take a few minutes to stretch and warm up before doing any kind of exercise.

It's best to incorporate a combination of both types of exercise into your lifestyle-moderate to vigorous physical activities to burn fat and strength training to build muscle. Neither is as effective alone.

At the same time, you need to reduce the amount of television you watch, since TV watching is independently associated with obesity.

Medications for Treating Obesity

Women with increased medical risk from their obesity may benefit from adding a weight-loss medication to their nutritional/exercise regimen.

Most research-based and professional associations recommend lifestyle therapy for at least six months before embarking on a weight-loss plan using physician-prescribed drug therapy. Even then, it must be used only as part of a comprehensive weight loss program that includes dietary therapy and physical activity. Currently available prescription medications include:

• phentermine (Adipex-P, Fastin, Ionamin, Obenix, Oby-Cap, Teramine, Zantryl)

• diethylpropion (Tenuate, Tepanil)

• phendimetrazine (Adipost, Bontril, Melfiat, Obezine, Phendiet, Plegine, Prelu-2)

• sibutramine (Meridia)

• orlistat (Xenical)

Orlistat also is now available over the counter under the brand name Alli in 60 mg pills, half the strength of the prescription dosage in Xenical. It is the first FDA-approved over-the-counter weight loss drug. Like Xenical, Alli blocks digestion of about 25 percent of the fat eaten at a meal. Orlistat has been found to be safe and effective in combination with a low-fat (less than 30 percent fat), low-calorie diet and can help people lose 50 percent more weight than dieting alone.

Most of these appetite suppressants have been approved for short-term use, meaning a few weeks or months. Sibutramine and orlistat are the only weight-loss medications approved for longer-term use in significantly obese patients, although their safety and effectiveness have not been established for use beyond two years.

Most of these drugs decrease appetite by affecting levels of certain brain neurotransmitters that affect appetite. Orlistat does not act directly on the central nervous system but instead blocks an enzyme essential to fat digestion so your body doesn't absorb fat.

On average, weight-loss drugs lead to loss of 10 pounds more than what you might lose with nondrug obesity treatments. If you are, may be or could become pregnant or are nursing, be sure to tell your health care professional. The effects of most of these drugs have not been tested on unborn babies; however, medications similar to some of the short-term appetite suppressants have been shown to cause birth defects when taken in high doses. Also, diethylpropion and benzphetamine pass into breast milk.

If you are considering taking drugs for weight loss, remember: NEVER take a drug or herb that hasn't been prescribed or recommended by your health care professional. There are numerous potentially dangerous over-the-counter drugs and herbs that claim to help you lose weight, but, except for Alli, they have not been approved by the FDA and may cause significant health complications and even death.

Surgery

For clinically severe obesity, your health care provider may recommend surgery. Many people, including some health care professionals, wrongly believe that obese people merely need to stop eating so much to lose weight. In reality, extreme obesity is a potentially deadly disease that sometimes requires a treatment as dramatic as surgery. Surgery is an option for carefully selected patients under the care of a health care professional. The surgery, called bariatric surgery, reduces the size of your stomach, limiting the amount of food it can hold. Most physicians consider people for the surgery who:

• have tried other methods of weight loss (changes in eating behavior, increased physical activity and/or drug therapy) and are still severely obese

• have a BMI of at least 40 (or 35 in addition to other medical conditions such as diabetes, hypertension and heart failure)

• understand the procedure, risks of surgery and effects after surgery

• are motivated to make a lifelong behavioral commitment that includes well-balanced eating and physical activity needed to achieve-and maintain-desired results

There are several types of bariatric surgery:

• Roux-en-Y gastric bypass (RYGB). In this procedure, sometimes known as "stomach stapling," the stomach is reduced to the size of a golf ball. The stomach is divided into a large portion and a small portion. The small portion is sewn or stapled together to make a small pouch, which holds only about a cup of food. The small pouch is then disconnected from the upper portion of the digestive tract and reconnected to a lower portion of the intestine. Not only do you eat fewer calories, but your body absorbs fewer calories because part of the intestine, the duodenum, has been bypassed.

• Adjustable gastric band. This procedure is performed laparoscopically, through a small incision in the abdomen. The surgeon wraps a saline-filled silicone band around the top of the stomach to create a small pouch about the size of a thumb. The size of the pouch can be altered by increasing or decreasing the amount of saline (salt water) in the pouch. You eat less because you feel full sooner.

Other less common procedures include:

• Biliopancreatic bypass with duodenal switch (BPDS). In this procedure, much of the stomach is removed, leaving only a "gastric sleeve" that is attached to the small intestine, completely bypassing the duodenum and upper small intestine.

  In a similar procedure, called biliopancreatic diversion with duodenal switch, a smaller portion of the stomach is removed, and the remaining stomach (gastric sleeve) remains attached to the duodenum. The duodenum is connected to the lower part of the small intestine. As with the gastric bypass procedure, you absorb fewer calories with both of these procedures. You also eat less because your stomach is so much smaller. Removing part of the stomach is also thought to reduce production of an appetite-related hormone called grehlin.

• Gastric sleeve. This procedure is actually the first part of the surgery performed in the BPDS, only the remaining pouch does not bypass the intestine. About three-quarters of the stomach is removed, and the remaining narrow pouch-or sleeve-connects to the intestines This procedure seems to be effective on its own and has shown excellent results, although it is still considered investigational.

All procedures can lead to "full and rapid" remission of diabetes, sleep apnea, hypertension, kidney failure and other weight-related medical conditions.

While bariatric surgery is extremely safe, the greatest risks come after the surgery. Some occur soon after the operation, such as hemorrhage, obstruction, infection, hernias, pulmonary embolisms (blood clots in the lung) and leaks between the areas where tissue was sewn together.

Long-term complications include nutritional deficiencies, including malabsorption of vitamin B12, iron and calcium; and hypoglycemia, or low blood sugar, which can lead to various medical conditions, including neuropathy.

Most people undergoing bariatric surgery have rapid and extreme weight loss. In one study of 608 patients followed up to 16 years, the average weight loss was 106 pounds. Nearly all the weight is lost by the second year after surgery. An estimated five to 10 percent of patients do not lose much weight, or regain the weight, with higher rates seen in those who undergo the gastric banding procedure.

After surgery, you have to learn to eat smaller amounts of food at one time, to chew food well and to eat slowly. If you don't adjust your eating habits, you won't lose as much weight. Additionally, especially in the first three months after surgery, you must be sure to eat the proper amounts of protein, calories, minerals and vitamins as recommended by your health care professional and you will likely need nutritional supplements for the rest of your life.

Behavioral Strategies

Another key to successful weight loss is incorporating behavioral strategies into your new eating and exercise activities. These include learning about nutrition, planning what to eat and making sure you eat regularly to end impulsive and thoughtless eating.

Some specific and helpful behavioral strategies include:

• Set the right goals. Your goals should focus on specific dietary and exercise changes, such as "I will eat five servings of fruits and vegetables every day this week," or, "I will work up to being able to walk briskly for 30 minutes at a time," rather than just on weight loss. Select two or three goals at a time to incorporate into your lifestyle rather than trying to change everything at once. Effective goals are specific, attainable and forgiving, which means that you don't have to be absolutely perfect. Remember, too, in setting your goals, that losing more than one to two pounds per week can be unhealthy and greatly increases the chances of regaining the weight.

• Reward success. To encourage yourself to attain your goals, reward yourself for successes. An effective reward is something that is desirable and timely such as attending the cinema or taking an hour for yourself. Don't use food as a reward!

• Keep a food and exercise diary. Many behavioral psychologists believe it's necessary to track your daily food consumption to achieve long-term weight loss. From a simple pad of paper to a computerized program that provides reports and analyses of your progress, the best tool is the one you use every day. Incorporate your goals, such as eating five servings of fruits or vegetables each day, into your self-monitoring efforts.

• Monitor your weight sensibly. Keep track of your weight, but don't weigh too often. One day's diet and exercise patterns won't have a measurable effect on the scale the next day, and your body's water weight can change from day to day, which may frustrate you and derail your efforts.

• Join a support group. Weekly meetings at a nearby support group or even over the Internet can help in a variety of ways. They provide accountability, helpful ideas, emotional support, an outlet for sharing frustrations and a variety of other psychological benefits.

• Use positive self-talk. Take responsibility and see yourself as in control, able to talk yourself into exercising every day rather than being angry, hopeless or in denial.

• Find ways other than food to respond to stress and other situations in your life. Certain cues, from stress to watching television, may stimulate unhealthy eating. In some cases, you can avoid those cues; don't go to that Mexican restaurant where you always eat too many chips, for example. For situations that can't be avoided, however, such as the business lunch or an argument with your spouse, relearn new ways to respond. If you track the situations surrounding your overeating in your food diary, you can more easily determine the cues you need to be aware of.

• Change the way you go about eating. There are a variety of tricks-from using a smaller plate to eating more slowly-that can help you eat less. Setting an eating schedule, starting meals with a broth-based soup, only buying foods on a pre-planned menu, using a meal replacement once or twice a day and other similar efforts can all help.

• When eating out, don't feel compelled to finish your entire meal if portion sizes are too large. The steady growth of food portion sizes served both in restaurants and at home has encouraged the overeating that is fueling the obesity epidemic in the United States, according to a survey by the American Institute for Cancer Research.

• Appropriate portion size is very important. When dining out, for instance, try to take home at least half of your dish. When eating at home, serve your plate and leave the remaining food in the kitchen; do not place it on the table. Half of your plate should be filled with vegetables, one quarter with a protein and one quarter with a starchy vegetable. Never, ever, supersize any kind of fast food or take-out meal.

Prevention

Prevention

Health care professionals and researchers stress that if you are obese, losing as little as five to 10 percent of your body weight can improve or prevent many of the health problems linked to your condition, such as high blood pressure and diabetes.

Facts to Know

Facts to Know

1. The rate of obesity in the United States has risen from 12 percent in 1991 to 32 percent today. One reason: Americans are eating more calories than they did 30 years ago.

2. Another contributing factor to obesity: Less than half of Americans exercise regularly, and nearly 25 percent are not active at all.

3. Obesity is the second leading cause of preventable death in the United States and contributes to $117 billion a year in health care costs. The Centers for Disease Control and Prevention reports that 32 percent of American women 20 years of age and older are obese.

4. One measure of obesity is your body mass index (BMI), which can be determined by dividing your weight in pounds by your height in inches squared and then multiplying by 703. For example, a woman who is 5'6" and weighs 190 would have a BMI of 31, as follows:

   • 5'6" = 66 inches
   • 66 squared = 4,356
   • 190 divided by 4,356 = 0.0436
   • 0.0436 x 703 = 30.65 (rounded up to 31)

5. If a woman's BMI is 30 or greater, she is considered obese. A BMI of 40 or more puts her in the extremely obese category. However, if she has more muscle mass than normal, these numbers won't apply, and her health care professional should measure her body composition to determine her degree of overweight.

6. If a woman's waist circumference is more than 35 inches, she is considered to have a high amount of visceral fat, which is the type of fat that surrounds the internal organs. This type of fat is associated with higher risk of certain diseases and conditions like diabetes and heart disease.

7. If you eat 250 calories per day fewer than needed to maintain your weight and exercise enough to burn an additional 250 calories a day, you will lose about a pound per week.

8. Several factors go into the calculation of your basal metabolic rate (BMR), or the number of calories your body needs just to maintain its basic functions, including your height, weight and age. To get an idea of your BMR, go to www.bmi-calculator.net/bmr-calculator/. You need additional calories to provide energy for daily activities; the more active you are, the more calories you need.

9. Obesity surgery, called bariatric surgery, reduces the size of your stomach, limiting the amount of food it can hold. Physicians typically consider it only for patients who have tried other weight loss methods and are still severely obese. Most people undergoing bariatric surgery have rapid and extreme weight loss, but they must commit to changing their eating habits and will likely need nutritional supplements for life.

10. The current U.S. Dietary Guidelines recommend that women who want to manage body weight and prevent unhealthy weight gain engage in 60 minutes of moderate to vigorous aerobic exercise on most or all days of the week while not exceeding caloric intake requirements. The best way to keep weight off once it's been lost is with 60 to 90 minutes of moderate-intensity exercise per day, also while being careful not to exceed your specific daily calorie requirement.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about obesity so you're prepared to discuss this important health issue with your health care professional.

1. Have my body composition and risk factors—as well as my height and weight—been considered in your diagnosis?

2. Based on my current weight and eating patterns and goal weight, how many calories a day should I eat in my weight loss efforts?

3. Based on my fitness level, how much and what types of exercise would be best for me to start with?

4. Do I need to undergo an electrocardiogram or other type of test before beginning an exercise program? What is my resting heart rate? What should my heart rate be while I'm exercising? What signals should I watch out for while I'm exercising that could tell me I'm overdoing it?

5. I know it will take time and effort to change my eating and physical activity habits. Can you recommend a registered dietitian to help me achieve my goals?

6. How will I be evaluated to determine if I am an appropriate candidate for appetite suppressant medication treatment?

7. What other medical conditions or medications might influence my decision to take an appetite suppressant medication?

8. Am I a candidate for obesity surgery? Why or why not?

9. What are the complications or possible side effects of any type of diets, medication, surgery or other treatment you are recommending? What symptoms should I watch for?

10. What kind of program will help me maintain my weight loss?

Key Q&A

Key Q&A

1. What's the difference between being obese and being overweight?

   In both overweight and obese people, the defining characteristic is excess body fat. The difference is a matter of degree. Overweight people usually have a body mass index (BMI), or ratio of weight to height, of 25 to 29.9. Obesity is usually defined as a BMI of 30 or more. Another measure of obesity is having more than 30 percent body fat. While overweight people have a higher incidence of certain diseases and conditions than normal weight individuals, as people gain weight, they become even more prone to these often life-threatening problems.

2. I'm more than 20 percent overweight, but I'm happy and satisfied with my life, so why should I care about my weight?

   Being overweight, and particularly, being obese, is bad for your health, even if you're only slightly overweight. It is a major risk factor for heart disease and stroke and is linked to a higher incidence of diabetes, which you are twice as likely to develop as a person of normal weight. In addition, it is associated with several types of cancers, gout, gallbladder disease and other diseases.

3. According to the charts, I'm categorized as obese, but I don't look fat, and I exercise at least five times a week, doing both aerobic exercises and weight training. What's going on?

   Chances are you are one of the individuals who don't fit neatly into the BMI or height/weight charts because you have a significant amount of muscle, which is denser-and therefore, heavier-than fat and makes your weight seem above the normal limits. What's really more important to consider is your body composition-your proportion of fat to muscle. As an avid exerciser and weight lifter, it's doubtful your body fat is greater than 30 percent, but if you are truly concerned, you can ask your health care professional to do a body composition test.

4. At 240 pounds, I have more than 80 pounds to lose. I feel like I'll never achieve that. Should I just give up?

   No. Losing as little as five to 10 percent of your body weight-in your case, 12 to 24 pounds-can significantly improve your health. Health care professionals recommend that your first effort at losing weight should be at this level, followed by a period of maintenance before trying to lose more.

5. I realize I need to lose weight. How should I start?

   The safest way to lose weight is, in most cases, to eat a nutritionally complete diet that cuts about 250 calories a day from the number of calories your body requires to maintain its present weight, plus add an exercise regime that burns an additional 250 calories a day. If you do this, you will lose about a pound a week.

   All of these moderate-intensity activities will burn at least 250 calories per hour for a 140-pound, healthy woman:

   • hiking (386 calories)
   • light gardening/yard work (302 calories)
   • dancing (319 calories)
   • bicycling, less than 10 mph (370 calories)
   • tennis, singles (386 calories)
   • walking, 3.5 mph (370 calories)
   • yoga (336 calories)

    

   More vigorous activities, such as calisthenics, running, swimming, downhill skiing and high-speed bicycling, will burn 500 or more calories per hour.

6. Do I have to exercise?

   No, you don't have to, but it is extremely beneficial. Not only will exercise make the weight come off more quickly and easily, it will make your weight loss much easier to maintain. If you do lose the weight without exercising, you will still be unfit, which is, in itself, a health hazard.

7. I've heard some nightmare stories about stomach stapling and other obesity-related surgical procedures. Are they safe?

   For clinically severe obesity, obesity surgery, called bariatric surgery, is safer than remaining severely obese. Because there are various types of operative procedures, you should speak with your health care professional about the specific safety statistics of the ones that might be best for you. In addition, consistent follow-up and patient compliance with post-surgical treatment is crucial to the success of these surgeries. These surgical procedures are used only in patients who have been unsuccessful at losing weight in other ways. There is a type of surgery that was common 10 or so years ago-intestinal bypass-which was dangerous and led to many cases of life-threatening side effects and even death. This type of surgery isn't done anymore.