肥胖治疗不只需要调整生活型态


  【24drs.com】四名肥胖专家在一篇新的评论文章中表示,肥胖是复杂的医疗问题,除了建议控制饮食与运动之外,还需要多种方式并行。
  
  第一作者、纽约西奈山伊坎医学院心理医师Christopher N Ochner博士表示,治疗肥胖时,仅建议改变生活型态往往是不够的;相对的,要实施多元策略-而不只是坚持要求他们的饮食-这可能包括适当使用药物或迷走神经阻断或手术。
  
  
  该篇报告也建议医师对已经过重的人制定以生活型态为基础的策略,借以预防肥胖,Ochner博士建议,不要等到人们已经肥胖了才对他们提出要适当营养与运动。
  
  作者们也建议,要建立维持减重的策略,因为维持适当体重比减重更困难。
  
  另外,也很重要的是,Ochner博士表示,不要责怪病人无法藉由控制饮食与运动来维持减重。不幸的是,我们大多仍认为肥胖者应该要成功,除非是缺乏意志力,这其实是错误观点且可能会造成伤害。
  
  Ochner博士与共同作者—丹佛科罗拉多大学内科医师Adam G Tsai、美国肥胖医学委员会主席、芝加哥生活型态医学中心的Robert F Kushner医师、费城宾夕法尼亚大学体重与饮食异常中心的Thomas A Wadden博士—在2015年2月12日的Lancet Diabetes & Endocrinology期刊,在线发表他们的评论意见。
  
  亚利桑那州Scottsdale减重中心的Craig Primack医师受邀对这评论发表看法时表示,他同意多项结论。
  
  从变重的那一刻开始,人们会被告知「你必须要控制饮食和多运动」,但是我们往往无所适从,人们会认为是个人因素造成失败。我们常常在一月开始控制饮食,但在二月就停止。这是一种荷尔蒙问题,有些减肥药可以「重置」下丘脑。
  
  但是,英国国家肥胖论坛主席、Luton & Dunstable医院的David Haslam医师强调,改变营养与增加运动是每种减重方法的基础。药物减重是额外的方式,但只有在明确的营养与运动建议下有效,也只有这样才可以维持减重。
  
  该文仅代表作者的意见,不代表任何组织-即便四位作者都是美国肥胖协会的会员。
  
  这篇评论的想法来自该协会公共事务委员会的一些成员,Ochner博士表示,表达出对许多医师仍旧相信的论点「只要少吃与多运动就足以治疗慢性肥胖,如果没成功,是病人的错」的关注。
  
  他与共同作者解释,限制热量诱发人体原本防止饥饿的生物适应,而现在确认的是,改变生活方式而促进多余的热量消耗和脂肪储存的长期有效性。
  
  他们写道,因为持续肥胖有很大的程度属于一种生物介质疾病,需要更多以生物为基础的介入方式,以因应维持最高体重的代偿适应。抗肥胖药物、减重手术以及新核准的腹腔内迷走神经阻断装置,个别可以不同程度地实现这一点。
  
  作者们提供了过重者预防肥胖、以及治疗肥胖的小秘诀,对于预防,他们建议医师提出适当营养与运动的重要性,对于已经减重者,要提供他们维持减重的资源。
  
  至于治疗,他们建议实施多元化个制化策略,可能包括高结构性饮食、高蛋白饮食、增加运动、药物、减重手术。也提到减重手术是唯一有效的长期肥胖治疗且应在适用时机提出建议。
  
  他们也建议,要告诉病患,有力的生物机转会造成体重增加,使用药物这些生物基础治疗并未意谓着意志薄弱。
  
  Primack医师表示,他提供减肥药给病人,且一开始就伴随生活方式谘商,不过,如果病人不要使用药物,他就不会开立。然而,如果患者用尽各种饮食控制方式或减重有限-使用药物会是相当有力的建议。
  
  Haslam医师强调的略有不同。他表示,就像血压-降血压药物可以减少中风负担,减重药物对于中风、糖尿病、睡眠呼吸暂停、脂肪肝、心血管疾病等等也是这样。所以,就我的观点,应促进使用它们(减重药物),但是,只有在良好的行为建议的情况下。我个人的实务是,先确保生活型态改变,但是对于使用英国现有的少数减重药物上也不要害羞。
  
  Ochner博士承认,现有的科学还未能精准分辨哪里些人对于哪里种治疗的反应最好,这已有被探讨,但还有漫漫长路要走。我们对于迷走神经阻断介入的资料有限,但是减重效果看起来是显著低于现有之减重技术所达到的。
  
  此外,不论我们是否认为需要付费,经济上的影响是相当大的,最需要的人一般无法负担治疗费用,我们正在争取更多第三方付款来负担[美国]的肥胖治疗。
  
  他结论指出,但愿这篇评论可以帮助推广以下讯息,我们正在处理一个相当程度的生物性疾病,需要像其它疾病一样有相同的代偿政策。
  
  资料来源:http://www.24drs.com/

Obesity Treatment Requires More Than Lifestyle Modification

By Miriam E Tucker
Medscape Medical News

Obesity is a complex medical problem that requires a multimodal approach beyond merely advising patients to go on a diet and exercise, four obesity experts say in a new opinion piece.

"When treating obesity, mere recommendations for lifestyle change are most likely insufficient," the lead author, psychiatrist Christopher N Ochner, PhD, from the Icahn School of Medicine at Mount Sinai, New York, told Medscape Medical News.

Instead, he said, "implement a multimodal strategy — as opposed to just insisting they diet — which may include the use of medications or vagal-nerve blockade or surgery as appropriate."

The paper also advises clinicians to formulate lifestyle-based strategies for prevention of obesity among people who are already overweight. "Don't wait until patients have obesity in order to address proper nutrition and exercise," Dr Ochner advised.

The authors also recommend the creation of strategies for the maintenance of weight loss, "which is far more difficult than weight loss."

Also important, Dr Ochner said, "Don't blame patients who are not able to maintain significant weight losses achieved via diet and exercise....Unfortunately, many of us still assume that the individual with obesity should have made it successful and, therefore, lacks adequate willpower. This view is incorrect and potentially damaging."

Dr Ochner and coauthors — internist Adam G Tsai, MD, from the University of Colorado, Denver; chair of the American Board of Obesity Medicine Robert F Kushner, MD, from the Center for Lifestyle Medicine, Chicago, Illinois; and Thomas A Wadden, PhD, from the Center for Weight and Eating Disorders at the University of Pennsylvania, Philadelphia — express their opinions in a comment published online February 12, 2015 in Lancet Diabetes & Endocrinology.

Asked for his thoughts on the piece, Craig Primack, MD, from the Scottsdale Weight Loss Center, Arizona, said he agrees with many of the conclusions.

"Since the beginning of time with weight, people have been saying you have to do more diet and exercise, and we're not getting anywhere. People take it as a personal failing.…A lot of times we start diets in January, but by February we're off. This is a hormonal problem. Some of the weight-loss medications can 'reset' the hypothalamus."

But chair of the United Kingdom's National Obesity Forum, Dr David Haslam, from Luton & Dunstable Hospital, Bedford, stressed, "Nutritional changes and increases in physical activity underpin each and every weight-loss attempt.

"Medications to reduce weight are a bonus but only work effectively in the context of sound nutrition and activity advice, and weight loss can be maintained only in that context," he added.

"More Biologically Based Interventions Are Likely to Be Needed"

The paper represents the opinions of the authors and not of any organization — although all four are members of the US Obesity Society.

The idea for the piece came from some members of that society's public affairs committee, who expressed concern that many clinicians still believe " 'just eat less and move more' should be sufficient to treat chronic obesity, and it's the patient's fault if it is not," Dr Ochner told Medscape Medical News.

He and his coauthors explain that caloric restriction triggers biological adaptations in the human body that were originally intended to prevent starvation but that now undermine the long-term effectiveness of lifestyle modification by promoting excess calorie consumption and fat storage.

"Because sustained obesity is in large part a biologically mediated disease, more biologically based interventions are likely to be needed to counter the compensatory adaptations that maintain an individual's highest lifetime body weight," they write.

Antiobesity drugs, bariatric surgery, and the newly approved intra-abdominal vagal-nerve–blockade device can all accomplish that to varying degrees, they note.

The authors provide tips for obesity prevention among overweight individuals and for the treatment of obesity. For prevention, they advise that clinicians address the importance of proper nutrition and physical activity, and for those who have lost weight, ensure they provide resources for weight-loss maintenance.

With regard to treatment, they recommend the implementation of a multifaceted individualized strategy, potentially including "highly structured diets, a high-protein diet, increases in physical activity, drugs, and bariatric surgery," noting that bariatric surgery is "the only effective long-term treatment for obesity available" and should be "recommended when appropriate."

They also advise, "Inform patients that powerful biological mechanisms encourage weight regain and use of biologically based treatments [such as] drugs is not a reflection of weak will."

Clinical Approach

Dr Primack told Medscape Medical News that he offers weight-loss medications to patients at the outset along with lifestyle counseling, although he doesn't push the drugs if the patient doesn't want to take them. However, "If they struggle at all, or have slow weight loss — and the more diets they've already been on — it becomes a stronger and stronger recommendation."

Dr Haslam's emphasis differs slightly. "Just as blood-pressure–lowering drugs reduce the burden of stroke, weight-loss drugs do likewise with regard to stroke, diabetes, sleep apnea, fatty liver, cardiovascular disease, and much more. So in my opinion, they should be promoted, but only in the context of good behavioral advice. My personal practice is to ensure lifestyle changes first but not to be shy of the (limited) weight-loss pharmacopoeia we have in the UK," he said.

Dr Ochner acknowledged, "The science is not precise enough yet to be able to tell exactly which patients will respond best to which of these treatments. This is something that is being explored but has a long way to go.…We have only limited initial data on the vagal-blockage intervention, but the weight loss appears to be significantly less than that achieved through modern bariatric techniques."

Moreover, he told Medscape Medical News, "reimbursement factors in quite heavily regardless of whether we feel it should. Those most in need generally cannot afford validated treatments out of pocket. We are desperately fighting for more third-party payers to reimburse for obesity treatments [in the United States].

"Hopefully, this piece will help spread the message that we are dealing with a disease that is in large part biological and deserves to have the same reimbursement policies as other diseases," he concluded.

Dr Ochner has received grants from Accera and nonfinancial support from ProBar. Dr Tsai has received nonfinancial support from Nutrisystem. Dr Kushner reports personal fees from Vivus, Takeda, and Novo Nordisk and grants from Weight Watchers. Dr Wadden reports personal fees from Nutrisystem, Orexigen Pharmaceutical, Novo Nordisk, Boehringer Ingelheim, Guilford Press, and Shire Pharmaceutical and grants from Novo Nordisk, Weight Watchers, and NutriSystem. Dr Primack is a speaker for Vivus, Novo Nordisk, Eisai and Takeda. Dr Haslam has no relevant financial disclosures.

Lancet Diabetes & Endocrinol. Published online February 12, 2015.

    
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