肥胖治療不只需要調整生活型態


  【24drs.com】四名肥胖專家在一篇新的評論文章中表示,肥胖是複雜的醫療問題,除了建議控制飲食與運動之外,還需要多種方式並行。
  
  第一作者、紐約西奈山伊坎醫學院心理醫師Christopher N Ochner博士表示,治療肥胖時,僅建議改變生活型態往往是不夠的;相對的,要實施多元策略-而不只是堅持要求他們的飲食-這可能包括適當使用藥物或迷走神經阻斷或手術。
  
  
  該篇報告也建議醫師對已經過重的人制定以生活型態為基礎的策略,藉以預防肥胖,Ochner博士建議,不要等到人們已經肥胖了才對他們提出要適當營養與運動。
  
  作者們也建議,要建立維持減重的策略,因為維持適當體重比減重更困難。
  
  另外,也很重要的是,Ochner博士表示,不要責怪病人無法藉由控制飲食與運動來維持減重。不幸的是,我們大多仍認為肥胖者應該要成功,除非是缺乏意志力,這其實是錯誤觀點且可能會造成傷害。
  
  Ochner博士與共同作者—丹佛科羅拉多大學內科醫師Adam G Tsai、美國肥胖醫學委員會主席、芝加哥生活型態醫學中心的Robert F Kushner醫師、費城賓夕法尼亞大學體重與飲食異常中心的Thomas A Wadden博士—在2015年2月12日的Lancet Diabetes & Endocrinology期刊,線上發表他們的評論意見。
  
  亞利桑那州Scottsdale減重中心的Craig Primack醫師受邀對這評論發表看法時表示,他同意多項結論。
  
  從變重的那一刻開始,人們會被告知「你必須要控制飲食和多運動」,但是我們往往無所適從,人們會認為是個人因素造成失敗。我們常常在一月開始控制飲食,但在二月就停止。這是一種荷爾蒙問題,有些減肥藥可以「重置」下丘腦。
  
  但是,英國國家肥胖論壇主席、Luton & Dunstable醫院的David Haslam醫師強調,改變營養與增加運動是每種減重方法的基礎。藥物減重是額外的方式,但只有在明確的營養與運動建議下有效,也只有這樣才可以維持減重。
  
  該文僅代表作者的意見,不代表任何組織-即便四位作者都是美國肥胖協會的會員。
  
  這篇評論的想法來自該協會公共事務委員會的一些成員,Ochner博士表示,表達出對許多醫師仍舊相信的論點「只要少吃與多運動就足以治療慢性肥胖,如果沒成功,是病人的錯」的關注。
  
  他與共同作者解釋,限制熱量誘發人體原本防止飢餓的生物適應,而現在確認的是,改變生活方式而促進多餘的熱量消耗和脂肪儲存的長期有效性。
  
  他們寫道,因為持續肥胖有很大的程度屬於一種生物介質疾病,需要更多以生物為基礎的介入方式,以因應維持最高體重的代償適應。抗肥胖藥物、減重手術以及新核准的腹腔內迷走神經阻斷裝置,個別可以不同程度地實現這一點。
  
  作者們提供了過重者預防肥胖、以及治療肥胖的小秘訣,對於預防,他們建議醫師提出適當營養與運動的重要性,對於已經減重者,要提供他們維持減重的資源。
  
  至於治療,他們建議實施多元化個製化策略,可能包括高結構性飲食、高蛋白飲食、增加運動、藥物、減重手術。也提到減重手術是唯一有效的長期肥胖治療且應在適用時機提出建議。
  
  他們也建議,要告訴病患,有力的生物機轉會造成體重增加,使用藥物這些生物基礎治療並未意謂著意志薄弱。
  
  Primack醫師表示,他提供減肥藥給病人,且一開始就伴隨生活方式諮商,不過,如果病人不要使用藥物,他就不會開立。然而,如果患者用盡各種飲食控制方式或減重有限-使用藥物會是相當有力的建議。
  
  Haslam醫師強調的略有不同。他表示,就像血壓-降血壓藥物可以減少中風負擔,減重藥物對於中風、糖尿病、睡眠呼吸暫停、脂肪肝、心血管疾病等等也是這樣。所以,就我的觀點,應促進使用它們(減重藥物),但是,只有在良好的行為建議的情況下。我個人的實務是,先確保生活型態改變,但是對於使用英國現有的少數減重藥物上也不要害羞。
  
  Ochner博士承認,現有的科學還未能精準分辨哪些人對於哪種治療的反應最好,這已有被探討,但還有漫漫長路要走。我們對於迷走神經阻斷介入的資料有限,但是減重效果看起來是顯著低於現有之減重技術所達到的。
  
  此外,不論我們是否認為需要付費,經濟上的影響是相當大的,最需要的人一般無法負擔治療費用,我們正在爭取更多第三方付款來負擔[美國]的肥胖治療。
  
  他結論指出,但願這篇評論可以幫助推廣以下訊息,我們正在處理一個相當程度的生物性疾病,需要像其他疾病一樣有相同的代償政策。
  
  資料來源: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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