A Critical Evaluation of Weight-Loss Interventions, and Long-Term Recommendations - Literature review Example

A Critical Evaluation of Weight-Loss Interventions, and Long-Term Recommendations Brad Cini Overweight and obesity are the results of unhealthy eating habits and lack of physical exercises. As an example, Elizabeth is obese and deserves an intervention that would help her mitigate her weight while at the same time enabling her to stay healthy under weight management program. As a recommendation, VLEDs (Very Low Energy Diets) are considered intervention methods in the short run. A related dieting and weight loss intervention method referred as VLCD (Very Low Calorie Diet) is recommended as it covers the long run interventional goals. Under the cognitive behavioral therapy, VLEDs and VLCDs are considered intervention methods to deal with obese patients. Focusing on Elizabeth, Aetna’s Benefit Plan accommodates her weight reduction objectives and provides explicit steps of managing weight. This document, although appreciates VLEDs as recommendable weight loss interventions contradicts with the aim of the current research as it only focuses on short-term weight reduction objectives. VCLD intervention program has been adapted in this case to address Elizabeth’s weight problem. A Critical Evaluation of Weight-Loss Interventions, and Long-Term Recommendations This review aims to assist the case of Elizabeth, a 38-year-old woman who is in need of evidence based recommendations for long-term weight loss interventions. The review will be conducted by a qualitative search methodology via Google Scholar, in reviewing the current state of research evidence over a wide range of different interventions. Specifically, the paper will attempt to define obesity, its prevalence and public health costs, with a focus on ethical considerations within the interventions. A combined approach of a low-energy diet and home/family based exercising intervention will be recommended for Elizabeth to manage her weight over long-term. Obesity Definition Obesity is classified as one of the most pressing concerns of public health, and is one of the leading causes of premature mortality also across the world (Douketis, Feightner, Attia, & Feldman, 1999; Rippe, Crossley, & Ringer, 1998). As in other countries, the problem of obesity represents a pressing issue in Australia, where regular monitoring is imperative in order to focus target preventive interventions (Flood, Webb, Lazarus, & Pang, 2000). There is a global consensus on the classification of obesity based on the Body Mass Index (BMI), which is calculated by an individuals body mass divided by the square of their height. The World Health Organisation and the National Institutes of Health classify a BMI of 25-29.9 as overweight, a BMI of 30-39.9 as obese, and a BMI of beyond 40 as severe obesity (Rippe et al., 1998). Aetiology Obesity has been conceptualised as a multifactorial disorder that can be caused or influenced by genetic, metabolic, environmental, socioeconomic and behavioral factors (Marín-Guerrero, Gutiérrez-Fisac, Guallar-Castillón, Banegas, & Rodríguez-Artalejo, 2008). According to this view, the specific contribution of each of these factors to the overall obesity epidemic varies significantly. Unlike behavioral factors, which have undergone significant modifications over human generations, genetic factors and their perceived influence on energy balance have remained constant, thus, cannot account for the rise in the obesity epidemic (Marín-Guerrero et al., 2008). In support of this perspective, Rippe et al. (1998) also conceptualise obesity as a chronic health disorder with a broad multifactorial aetiology ranging from genetics, environment, metabolism to lifestyle and behavioral factors. The rising prevalence of obesity (and overweight individuals) in the Australian population, like in the rest of the developed world, can be attributable to the increasing levels of physical inactivity as well as the shifts in food consumption patterns (Banwell, Hinde, Dixon, & Sibthorpe, 2005). Other research support this claim by attributing the prevalence of the obesity epidemic in low-income and middle-income countries to new dietary habits and sedentary lifestyles, which further aggravate the risk of chronic diseases and premature mortality in populations (Cecchini et al., 2010). Further, a recent study by Cheong, Kandiah, Chinna, Chan, and Saad (2010) also implicates socio-economic status, lifestyle habits, as well as psychosocial factors in the rising prevalence of both obesity and overweight individuals on a global scale. Prevalence Cases of overweight and obesity in the Australian population have shown a rising trend since the 1990s, and given the country’s progressively worsening obesogenic environment in contemporary times, the risk of obesity for more recently born cohorts is further aggravated (Allman-Farinelli, Chey, Bauman, Gill, & James, 2008). The prevalence of overweight and obesity in Australian children is particularly on a rising trend of nearly one percentage per year, which equates to nearly 40000 more children becoming overweight on a yearly basis (Sanigorski, Bell, Kremer, & Swinburn, 2007). It has been argued that Australian children rank highest in global estimations of obesity risk; this is especially evident in females and children of lower socioeconomic status. This is of particular concern since obesity in childhood is more likely to persist into adulthood thereby predisposing individuals to the heightened risk of disease burden in later life (John, Wolfenstetter, & Wenig, 2012). Evidence from a longitudinal nation study in Australia suggest that if the rates of weight gain remain constant, then the prevalence of obesity will rise by 65% while the proportion of normal-weight adults will be less than a third of the Australian population by 2025 (Walls et al., 2012). Interventions for Obesity History A major limitation in the development of interventions for obesity has been attributed to the global healthcare community not regarding obesity as a chronic disease, and the lack of physician involvement (Rippe et al., 1998). The lack of incentive for physician involvement in the treatment of obesity is attributable to numerous factors including the lack of reimbursement for obesity-related therapies in most insurance plans, high skepticism of the effectiveness of the prevailing therapies, as well as the persistence of negative societal prejudices that attribute obesity to a lack of discipline (Rippe et al., 1998). However, despite these limitations, some major clinical interventions in the treatment of overweight and obesity have emerged. Each of these therapies have been researched with varying levels of success in the treatment of obesity and are briefly discussed below to highlight the contrasting strategies used for clinical weight-loss. Pharmacological Therapy Significant advances have been made in the contemporary understanding of pharmacological treatments for eating disorders. Clinical tests point out the short-term effectiveness of antidepressants in cases of bulimia nervosa while highlighting the lack of evidence for the effectiveness of this treatment in severe cases (Kotler & Walsh, 2000). Anti-obesity drugs in particular, have been considered for individuals who haven’t achieve significant weight-loss outcomes through lifestyle change programs, diet and physical exercising (Hainer, 2011). Anti-obesity treatment drugs such as ephedrine and phenylpropanolamine stimulants are commonly recommended as weight loss supplements, yet there is insufficient evidence of both short and long term clinical trials of their weight-loss efficacy (Tek, Ratliff & Chwastiak, 2011). Furthermore, studies recommend that pharmacological treatments for obesity are more likely to yield positive outcomes when combined with appropriate behavioral or nutritional programs. For instance, Mersebach, Klose, Svendsen, Astrup, and Feldt‐Rasmussen (2004) established significant weight-loss in participants when combining effects of diet alongside exercise in obese hypo-pituitary patients. However, no post-treatment effects or follow-up data were reported. In terms of long-term maintenance, the obesity drug Topiramate has shown some success in maintaining weight loss in clinical trials, with only mild to moderate side effects (Astrup & Toubro, 2004). However, most trials with Topiramate have used behavioural interventions as an adjunct treatment, making it difficult to see the isolated effect of pharmacotherapy alone. Motivational Interviewing Motivational interviewing (MI) is a client-centered, directive therapeutic approach that is used to enhance an individual’s intrinsic motivation to alter their behavior, achieved by exploring and resolving ambivalence concerning changing behaviour (Low, Giasson, Connors, Freeman, & Weiss, 2013). It has been suggested that low-intensity MI counseling interventions can result in significant weight loss in the short term, but there is a paucity of evidence showing its effectiveness in the long-term (S. J. Hardcastle, Taylor, Bailey, Harley, & Hagger, 2013). In support of this view, S. Hardcastle, Blake, and Hagger (2012) further reiterate that motivational interviewing is more effective as a strategy for promoting physical activity, typically amongst socioeconomically disadvantaged groups in the short term. Centrality of Long-Term Maintenance For obesity interventions to be successful in resulting to significant positive outcomes in weight-loss, they should be able to yield a longer-term maintenance of weight-loss while preventing post treatment weight regain. The fact that it is not easy for individual’s with obesity to maintain weight-loss after intervention sustains the notion that obesity resists psychological interventions if a long term perspective is not undertaken (Cooper et al., 2010). In that respect, it is evident that most people might succeed in losing weight in the short term but may eventually regain a vast proportion of the lost weight, thereby highlighting the need for a paradigm shift in psychological research on obesity from treatment to prevention. Similarly, a number of recent studies express skepticism concerning obesity and weight-loss interventions by arguing that community-based obesity prevention methods are highly ineffective (Douketis et al., 1999). These studies further contend that except in a negligible proportion of obese patients who receive dietary and surgical treatments, obesity treatments are generally ineffective in the longer term, that is, over two years durations. In that case, there is no doubt that despite the effectiveness of intensive and regular physical exercise in preventing weight-gain, this strategy does not work for the entire populations since it is only effective in the short-term given the counteractive effect of societal forces that promote obesity (Anand, 2006). Ethical Considerations Adults present special challenges in adjusting to weight loss interventions. This is because, while weight loss problems in most children who are obese and overweight could be a result of dietary problems and genetic makeup, the case is very different for adults. Adults are faced by external factors such as stress, depression, economic challenges and social isolation, all of which are external factors that can affect the effectiveness of the weight loss intervention method that is applied (Xu et al., 2012). The majority of effective weight-loss interventions incorporate regular activity in addressing most of the chronic health conditions that are associated with obesity. However, the effectiveness of this intervention is largely dependent both on the level of motivation, as well as the mental state of the individual (Benyamini et al., 2013). Research have indicated that most women are sedentary and demonstrate a low level of leisure-time physical activity, which has resulted in a disproportionate number of woman with obesity compared to men (Kitson et al., 2013). However, there are a range of ethical contributory factors that might be affecting the ability of women to participate effectively in physical activities and other weight loss intervention programs. Obesity Stigma Obesity stigma is a major factor that deteriorates the psychological and the physical health of individuals with overweight and obesity problems (Puhl & Heuer, 2010). Nevertheless, the public health implication of this ethical issue has often been ignored. Some healthcare professionals fail to take an ethical approach when dealing with clients by commenting negatively on the weight and body shape of overweight and obese individuals as a way of motivating them to participate in weight loss interventions (Monteath & McCabe, 1997). The implication of such negative comments is that they increase the level of obesity and overweight stigmatisation of the individual, which arises from similar comments from family, friends and the society. Thus, instead of such negative comments helping the individuals affected by the overweight problem to adapt healthy behaviors, the comments serves to demoralise them, lower their self-esteem and self-confidence in the weight loss intervention programs, and consequently discourage them from effective participation (Xu et al., 2012) Obesity Stereotyping Obesity stereotyping is yet another major ethical issue that weight loss intervention programs must address adequately. There are numerous weight-based stereotypes circulating within society. Common stereotypes include; obese and overweight people are lazy, greedy, unintelligent, weak-willed, unsuccessful, non-committal to good health, unsuccessful, lack self-discipline and are non-compliant to the weight loss interventions (Puhl & Heuer, 2010). The use of these stereotypes can discriminate against individuals across many different societal platforms, starting with family and spousal interpersonal relationships, workplace discrimination, social events and even health facilities. The effect of such discrimination to overweight and obese individuals is that they are affected both psychologically and emotionally, which can lead to discouragement from participating in the relevant weight loss intervention programs. In this respect, it is not uncommon to have individuals who are obese or overweight being criticised by their coworkers, relationship partners, teachers, family, employers, physicians and friends (Kitson et al., 2013). Recent statistics have indicated that the prevalence of weight discrimination has increased by 66% within the past one decade, and thus the prevalence and effect of obesity and overweight discrimination is now being ranked the same as racial discrimination in America (Puhl & Heuer, 2010). Summary of Evidence for Long Term Weight-loss Interventions The recommended intervention that is effective in achieving weight loss for Elizabeth in the long-term must be capable of considering the multi-factorial causes of obesity (Marín-Guerrero et al., 2008). Therefore, a comprehensive intervention is needed to ensure both the dietary patterns and the physical exercise, which are primarily effective in addressing the obesity and weight loss, are addressed (Hainer, 2011). However, despite the perceived effectiveness of clinical weight-loss interventions in the short term (Tek, Ratliff, & Chwastiak, 2011), the evidence for long-term weight-loss sustainability from these interventions is sparse (Cooper et al., 2010). On a macroscopic level, as research shows the new dietary habits adapted by modern society, coupled with a sedentary lifestyle, are increasingly leading to higher rates of obesity and chronic disease (Banwell et al., 2005; Cecchini et al., 2010), any sustainable weight-loss intervention must take these factors into account. The intervention HIPP was specifically designed to address the ethical issue of lack of time and space for women to attend physical activity-based weight loss intervention programs (Pekmezi et al., 2013). In response, BT and VLED is able to target both dietary habits, activity levels, take ethical and practical considerations into account, and has a good evidence base for long-term sustainability. RECOMMENDATIONS Primary Recommendation Cognitive Behavioural Therapy VLED/VLCD According to the findings of International Association for the study of Obesity of 2001, 20 years of research have found that very low energy diets are recommendable for short-term weight management. However, the same research shows that the evidence on VLED is less satisfactory for long term interventions. The use of VLED as an intervention for weight loss is majorly practiced in obesity clinics as a weight loss program. However, with the consideration of published guidelines such as the Scottish Guidelines for weight management, VLEDs are best reserved for use in specialist centers for sufferers on clinical grounds, to achieve the weight loss objective rapidly or implemented where current and effective long-term weight maintenance is approach is available. With reference to location based interventions for weight loss, the NIH guideline used in the USA disapproves the use of VLEDs. For the short and long-term intervention, Australian programs that deal with weight loss refer to VLED as Very Low Calorie Diets (VLCD). For the case of Elizabeth, VLCDs are recommended as they are fully endorsed and supported by the Aetna plan. The Aetna plan, however, does not offer services or supplies to weight loss programs as its major concern is to provide guidelines such as those provided by other non-Australian guidelines. In this case, Elizabeth’s case is fully accommodated with the Aetna plan. The Aetna plan is a step by step weight loss implementation guideline that patients of obesity and overweight can regulate their weight using. Full information about the plan can be found within the plan’s website aetna.com which provides the benefits and the restrictions of the plan (NHS, UK., n.d). Implementation of VLCD Under the Aetna benefit plan guidelines, a patient such as Elizabeth must meet the criteria of having acquired weight reduction medications and having a clinician to supervise the weight reduction program. For Elizabeth’s case, Aetna plan provides the implementation guidelines while the VLCD is the program to handle the condition with. The following steps are recommended for a patient before he/she is considered legible for the VLCD intervention. Step 1: Weight Reduction Medications Aetna plan does not provide the coverage for weight loss medications neither does it provide the service of administering the process. Thus, in order for Elizabeth to be legible for the VLCD program, she should acquire weight reduction medications from a licensed physician or from a registered weight management clinic. Step 2: Weight Management Clinician Elizabeth should acquire a clinician to administer the VLCD program after she has complied with step 1 of the Aetna plan. In so doing, Elizabeth would have met the criteria for Aetna Benefit Plan. Step 3: Administering Medication Weight reduction medications are recommended for patients who have been unable to lose at least a pound in a week after being enrolled on a weight loss regimen for 6 months. Under this condition, Elizabeth has to ensure that she meets either of the two conditions listed below. a. BMI greater or equal to 30Kg/m2 b. BMI greater or equal to 27 kg/m2 coupled with either of the following risk factors i. Coronary heart disease, ii. HDL Cholesterol of 35 mg/dL of less iii. LDL cholesterol of 160 mg/dL of greater iv. Hypertension with systolic blood pressure of 140 mm Hg v. Diabetes mellitus type 2 vi. Obstructive sleep apnea Step 4: Clinical Supervision of VLCD Elizabeth is required to visit a weight reduction clinician not less than 26 times within a 12-month period if her MBI is 30 kg/m2. While at it, she is supposed to have comprehensive medical and physical examination, full-blown blood count, dexamethasone suppression test, urinary cortisol measure, electrocardiogram, lipid profiling, chemistry and metabolic profiling, T3/T4/THS thyroid function tests, and urinalysis. Step 5: VLCD Administration For up to 16 weeks, Elizabeth is required to have the following services administered under the VLCD intervention program: i. EKG (electrocardiogram) following 50lb weight loss ii. Lipid profiling at the start and end of the VCLD program iii. SMA liver function test and Serum chemistries on a weekly basis during the rapid weight loss period and once after every 2 weeks afterwards iv. If the VLCD extends to more than 16 weeks, it is recommended that the procedure be subjected to medical review Step 6: Diet Patterns According to the NHS guidelines, a patient on VLCD should reduce his or her daily calorie intake to 1000 and 1250 for women and men respectively. While trying to maintain healthy living, energy levels are necessary but the intake or calories should be limited to 2000 for cases such as Elizabeth’s. The recommended daily calorie intake is 2000 and 2500 for women and men respectively. However, VLCD requires far fewer calories from the recommended intake for healthy people. The 1000-calorie intake diet is recommended for 12 continuous weeks (NHS, UK., n.d). Ethical and practical concerns Ethical concerns in the management of obesity involve the commitment to the programs involved. Thus, Elizabeth is required to commit to her weight reduction program to ensure that she is able to lose and maintain a healthy BMI. However, some major health concerns include the inability to attend to the programs commitments throughout the 16 weeks. Additionally, it is a major concern for the patient to maintain healthy eating habits given that she has access to fast foods and other high energy and calorie meals (Mustajoki, & Pekkarimen, 2001). Weight-loss sustainability in the long-term Adding weight involves the consumption of high energy/calorie meals such as bread, French fries, red meat, yoghurts, and a paraphernalia of related meals. In order for Elizabeth to maintain a healthy living through sustained weight loss, she must be able to merge exercise with healthy eating habits. Healthy eating habits include the intake of enough water of up to five liters a day and vegetable means with white meat. Conclusion The use of VLED as an intervention for weight loss is majorly practiced in obesity clinics as a weight loss program. For the short and long-term intervention, other programs that deal with weight loss refer to VLED as Very Low Calorie Diets (VLCD). For the case of Elizabeth, VLCDs are recommended as they are fully endorsed and supported by the Aetna plan. The Aetna plan is a step by step weight loss implementation guideline that patients of obesity and overweight can regulate their weight using. Thus, in order for Elizabeth to be legible for the VLCD program, she should acquire weight reduction medications from a licensed physician or from a registered weight management clinic. Weight reduction medications are recommended for patients who have been unable to lose at least a pound in a week after being enrolled on a weight loss regimen for 6 months. While at it, she is supposed to have comprehensive medical and physical examination, full-blown blood count, dexamethasone suppression test, urinary cortisol measure, electrocardiogram, lipid profiling, chemistry and metabolic profiling, T3/T4/THS thyroid function tests, and urinalysis. According to the NHS guidelines, a patient on VLCD should reduce his or her daily calorie intake to 1000 and 1250 for women and men respectively. However, VLCD requires far fewer calories from the recommended intake for healthy people. The 1000-calorie intake diet is recommended for 12 continuous weeks (NHS, UK., n.d). 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