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PhilSPEN Online Journal of Parenteral and Enteral Nutrition

(Article 18 | POJ_0009.html) Issue February 2012 - December 2014: 19-28

Original Clinical Investigation

A Multidisciplinary Non-Surgical Approach in the Management of Obesity – Report of a Two-Year Experience in a Tertiary Care Hospital in the Philippines

Abstract | Introduction | Methodology | Results | Discussion | Conclusion | References | PDF (316 KB) |Back to Articles Page

Submitted: January 30, 2011 | Posted: July 8, 2014

AUTHORS:

    Mary Anne B. Santos, MD; ; Reynaldo P. Sinamban, MD; Fe S. Felicilda, MD; Catherine Carlos, MD; Divina Cristy S. Redondo, MD; Iree Velasco, RND; Ma. Nenita Umali, RND; Luisito O. Llido, MD

INSTITUTION WHERE RESEARCH WAS CONDUCTED:

  1. Weight Management Center, St. Luke’s Medical Center, Quezon City, Metro-Manila, Philippines
  2. Clinical Nutrition Fellowship Training Program, St. Luke’s Medical Center, Metro-Manila, Philippines

 

ABSTRACT: | Back

Background: Obesity and weight problems are increasing in the Philippines. A multidisciplinary weight management center was organized to deal with this emerging problem in a tertiary care hospital in the Philippines (St. Luke's Medcal Center, Metro-Manila).

Objective: This study reports on the outcome of the non-surgical weight management program of the center after two years of operation (2004 to 2006).

Methodology: All patients enrolled in the non-surgical management program were included in the study. Weight loss regimen was a series of packages which were combinations of diet management, exercise, and other ancillary approaches as designed by the team. Weight was regularly monitored and weight changes were verified by BIA. Weight loss goal was 3% to 5% per package. Statistical analysis used was paired samples t-test for normal data.

Results: 84 patients completed the packages. Male/female ratio was 1:1.3, mean age was 27.7 years, 40.5% were pediatric, 57.1% were adults, and 2% were geriatric. 5% weight loss was achieved within 45 to 150 days (2 to 5 months) and if patients persisted in the program reaching 400 days (more than one year) they achieved a 13% weight loss amounting to 13.5 kg (Std.Dev.: 16.38). BMI dropped to 5.04 points (Std Dev.: 6.26; P < 0.05 paired samples t-test). Significant weight loss started at 4.33 kg loss (P < 0.05; paired samples t-test). BIA showed that the significant weight loss was in the fat compartment (5 kg mean weight loss) while the body cell mass and total body water compartments had no significant changes. 76% of enrollees achieved their goals of weight loss.

Conclusion: Non-surgical multidisciplinary approach to weight loss can achieve significant results after the program reaching 13% excess weight loss in one year.

 

KEYWORDS: Obesity, Body Mass Index, BMI, multidisciplinary

 

INTRODUCTION | Back

The prevalence of obesity has become global in scope and has even reached serious levels so as to raise concern in several areas around the world [1,2,3]. In the Philippines two national surveys have shown a similar rise in the incidence of overweight and obesity [4]. The nutritional status surveillance of our hospital (St. Luke’s Medical Center) has shown that the overweight and obese hospitalized patients occupy a large portion of the hospital in patient population [5]. When the four-year data of overweight and obese was analyzed (years 2000 to 2003) it showed that the obese patients comprise 8-10%, and the overweight patients comprise 20-30% of the whole hospital population.

These data, together with the global trend of increasing overweight and obese population, has spurred the establishment of a weight management center whose main purpose is to provide a multidisciplinary approach to the management of either the underweight or overweight. The whole system was based on the realization that weight problems, especially for the overweight and obese, are multi-factorial and as such require several specialists acting as one team in managing a patient (?).

Since the data comes from the in-patient hospital population the team has decided to establish a center that manages both the in-patient and out-patient population in order to fully cover the patients who have these problems and accomplish the hospital to home continuity of care or vice-versa. The center started the program on January 2003 and this is the progress report of the results obtained for a period of two years (January 2004 to December 2006).

 

METHODOLOGY | Back


The weight management team: is composed of a medical and administrative staff. The medical staff consists of the following specialists: endocrinologist (N=6), rehabilitation medicine specialist (N=1), cardiac rehabilitation specialist (N=1), pulmonary medicine specialist N=(1), nutrition support physician (N=2), psychiatrist (N=2), and bariatric surgeons (N=4). The administrative staff (or allied medical staff) consists of the following: weight management nutritionist-dietitians (N=2), physical therapists (N=2), and nurse (N=1).

 The approach to weight management: Weight management of the overweight and obese has two phases. The first phase is the non-surgical approach utilizing the following: nutrition screening and assessment, diet management, endocrine evaluation, cardiopulmonary assessment and follow up, psychiatric assessment and management, exercise program prescription followed by the actual therapeutic exercises. Pharmacotherapeutic agents are used and monitored. The second phase consists of the surgical approach where the patient undergoes several options of bariatric surgery procedures. Specific criteria have been set for the inclusion of patients in the surgical phase.

The non-surgical phase of weight management: This phase covers both the adult and pediatric patient population. The first process performed is nutrition screening where the following procedures are done – Body Mass Index (BMI) determination, Waist and Hip Circumference measurement, and risk determination utilizing the AACE[?] and PASOO[?] guidelines. Bioelectric impedance analysis is then done on the patients. Once the patient has been fully examined by the weight management consultant he/she is provided with a weight management package, which has the following features. The therapeutic package for adults covers three months of intensive weight management procedures. Prior to initiating the diet and physical activity routines the patient undergoes the following examinations: DIME 12(?), CBC, Urinalysis, ECG, Treadmill exercise testing, TSH, and modified OGTT (2 hours). Then the patient goes through the whole program where an endocrine evaluation is performed (4 sessions), cardiopulmonary clearance and follow-up with the cardiologist, psychiatric therapy (2 sessions), nutrition counseling (6 sessions), exercise prescription (2 sessions), and therapeutic exercises (36 sessions). The pediatric patients undergo a similar package with the addition of the following features: family counseling by the psychiatrist (3 sessions) and regular sessions with the weight management pediatrician. Once the patients have completed the therapeutic package they are then given the maintenance package, which is similar to the therapeutic package except for the duration, which is now determined by both the patient (or family) and the weight management team.

All patients enrolled in the packages were eligible for inclusion in the study. Data gathered were patient profile: age, sex, BMI ranges. The initial and final weight records and body composition changes as documented through the bioelectric impedance analysis (BIA) machine were collected. Only patients with complete weight and body composition records were included, however, we presented the success rates of the program during the first year of operation to show the general trends of weight loss. Statistical analysis used: means and standard deviations of the different variables; chi square for nominal data, and for the differences in means: t-test for normal distributed data and non-parametric tests for non-normal data. Statistical analysis was performed using the SPSS (Statistical Package for Social Sciences) version 11 software (Copyright 2001 by SPSS, Inc).


RESULTS | Back

A total of 84 patients completed their weight management packages in the center (Table 1). The over-all mean age is 34 years (range: 6 to 70 years) while the BMI ranges from 13.5 to 83. The BMI distribution is: 0.6% (1) is underweight, 5.2% (9) are normal, 19.8% (34) are overweight, 37.2% (64) are obese, and 37.2% (64) are morbidly obese. There are more females (105 or 61%) than males (67or 39%) enrolled giving a 1.6:2 male:female ratio. Male/female ratio was 1:1.3, mean age was 27.7 years, 40.5% were pediatric, 57.1% were adults, and 2% were geriatric.

wtmgttbl01

5% weight loss was achieved within 45 to 150 days (2 to 5 months) and if patients persisted in the program reaching 400 days (more than one year) they achieved a 13% weight loss amounting to 13.5 kg (Std.Dev.: 16.38). (Figure 1) BMI dropped to 5.04 points (Std Dev.: 6.26; P < 0.05 paired samples t-test). Significant weight loss started at 4.33 kg loss (P < 0.05; paired samples t-test).

wtmgtfig01

BIA showed that the significant weight loss was in the fat compartment (5 kg mean weight loss) while the body cell mass and total body water compartments had no significant changes. (Figure 2) 76% of enrollees achieved their goals of weight loss.

wtmgtfig02

 

Patient profile:

Over-all picture: The mean age is 31.9 years and it ranges from 6 to 70 years old. There are more females than males (61% versus 39%) and the weight patterns are as follows: over-all mean weight is 98.3 kg with weight range of 32-166 kg; for males, mean weight is 110.9 kg with weight range of 52-166 kg; and for females, mean weight is 78.2 kg with weight range of 32-148.2 kg. The over-all mean initial BMI is 34.3 with range of 13.5-49.8; for males, initial mean BMI is 38.1 with range of 28.1-59.8; and for females the mean initial BMI is 31.5 with range of 13.5-55.8.

Pediatric population (30% of the total non-surgical population, n=34): The mean age is 13.6 years with age range of 6 to 18 years old. The BMI ranges from 21.6 to 56.9. The BMI distribution shows: 23.5% (8) are overweight, 44.1% (15) are obese, and 23.5% (8) are morbidly obese (age range: 11 to 18 years old). There is an equal distribution of sexes in most of the BMI groupings except in the morbidly obese where there are more males than females (88% vs. 12%).

Adult population (64% of the total non-surgical population, n=72): The mean age is 31.9 years with the age range of 19 to 57 years old. The BMI ranges from 13.9 to 59.8. The BMI is distributed as follows: One patient was underweight (BMI = 13.5) and enrolled for weight gain purposes, 26.8% (19) are overweight, 38% (27) are obese, and 28.2% (20) are morbidly obese (BMI range: 40.2 to 56.8; age range: 24 to 56 years old). There are more females compared to males (63% vs. 37%), but as in the pediatric age group, there are more males than females in the morbidly obese group (60% vs. 40%).

Geriatric population (6.2% of the total non-surgical population, n=7): The mean age is 65.7 years with the age range of 62 to 70 years. The BMI ranges from 26.6 to 42.3. The BMI distribution is: 42.9% (3) are overweight, 42.9% (3) are obese, and 14% (1) is morbidly obese (BMI = 42.3). There are more males than females (71% vs. 29%), and again the morbidly obese is a male patient (1).

Package utilization and weight reduction outcome:

The mean weight loss achieved by the program is 6.2 kg (95% C.I.: 4.9-7.4 kg) or 6.7% weight reduction (p < 0.001, paired samples t-test) which was attained by 50.4% (57/113) of patients. For the over-all results: 80% lost weight, 78.8% achieved the 2% weight loss goal starting on day 4, 53.1% reached 5% weight loss goal within day 8, 23.9% achieved 10% weight reduction also by day 8 of the program, 10.6% of patients achieved 15% weight reduction goal within the 63rd day of the program and 5.3% achieved 18% or more weight reduction starting on day 112 of the program (Table 2 and Figure 1 and 3). The mean BMI of 34.3 at the start of the program dropped to 32.3 at the end of the program.

wtmgttbl02

For the obese patients (n=45), 84% lost weight, 80% reached 2% weight loss goal within 4 days, 69% reached 5% weight loss goal within 30 days, 27% reached 10% weight loss goal in 60 days, 11% reached 15% weight loss goal in 100 days, and 4% attained 20% weight loss in 112 days. The mean weight loss for obese patients is 6.32 kg (95% C.I.: 4.77-7.87 kg) or 6.5% weight reduction attained by 64.4% (29/45) of obese patients. The mean BMI of 33.7 at the start of the program dropped to 31.6 at the end of the program.

For the morbidly obese patients (n=29), 86.2% lost weight. 82.8% attained the 2% weight loss goal in 34 days, 58.2% reached the 5% weight loss goal also in 34 days, 34.5% reached 10% weight loss in 64 days, 21% reached 15% weight loss also in 64 days, and 7% reached 20% weight loss in 273 days. The mean weight loss for morbidly obese patients is 10.7 kg (95% C.I.: 7.3-14.2 kg) or 7.7% weight reduction attained by 58.6% (17/29) of morbidly obese patients. The mean BMI of 45.8 at the start of the program dropped to 42.5 at the end of the program.

These are the specific changes noted in every period of the weight reduction program:

  1. 30 days completed: 9.7% (11) of patients achieved a mean 1.88% weight loss (1.54 kg, not significant, paired samples t-test). Maximum weight loss was equal to the mean weight loss. 45.5% attained the 2% weight loss goal. Mean BMI started at 33.5 and lowered to 32.9.
  2. 60 days completed: 16.8% (19) achieved a 3.53% mean weight loss (3.6 kg, p = 0.001, paired samples t-test). Maximum mean weight loss was higher at 3.8 kg (3.75%). 57.9% attained their weight loss goal of 2%. Mean BMI started at 30.7 and closed at 29.4.
  3. 90 days completed: 9.7% (11) of patients achieved a mean 5.6% weight loss (6.7 kg, p = 0.022, paired samples t-test). This is higher than the programmed 5% weight loss. Maximum weight loss attained was slightly greater at 6.9 kg (5.8%). 54.5% of patients reached the 5% weight loss goal. The initial mean of BMI of 34.1 dropped to 31.8.
  4. 180 days completed: 38.9% (44) of patients achieved a 6.8% mean weight loss (6.4 kg, p < 0.001, paired samples t-test). Maximum weigh loss reached was 6.8 kg (7.2%). 66% reached their weight loss goal of 5% and subsequent maintenance. Mean BMI started at 35.2 and closed at 32.5.
  5. 270 days completed: 10.6% (12) of patients achieved 5.5% mean weight loss (5.3 kg, p =0.007, paired samples t-test). Maximum weight loss attained was 6.7 kg (7.3%). 50% achieved the 5% weight loss goal. Initial mean BMI started at 32.8 and closed at 30.4.
  6. 360 days completed: 7.1% (8) of patients achieved 6.8% mean weight loss (8.8 kg, not significant, paired samples t-test). Maximum loss attained reached was 11.3 kg (9.8%). 50% achieved the programmed 5% weight loss goal. Initial mean BMI was 36.2 and mean closing BMI was 32.1.
  7. More than 360 days: 7.1% (8) of patients achieved 4.8% weight loss, which is lower than the 5% goal (3.6 kg, NS, paired samples t-test). Maximum weight loss attained was 9.6 kg (8.1%). 37.5% reached their goal. Initial mean BMI was 39.6 and closing mean BMI is 37.3.

wtmgtfig03

 

DISCUSSION: | Back

Goals of weight management interventions include prevention or stopping weight gain in an individual who has been seeing a steady increase in his or her weight with varying degrees of improvements in physical and emotional health and improvements in eating, exercise, and other behaviours(4).

Based on the results of this study, a weight loss of 12.7%  (13.5 kg)  was achieved in one year by subjects who were enrolled until the phase 8 of the program due to a continuation of the prescribed program. Our data is somewhat similar in  a recent systematic review of long-term weight loss after diet and exercise clinical trials, Curioni reported that individuals in a diet and exercise group had a mean weight loss of 13 kg after intervention(5). However, Douketis et al reported results of the review  on dietary and lifestyle  interventions provided <5kg weight loss after 2 to 4 years, and pharmacologic therapy provided 5 to 10 kg weight loss after 1 to 2 years(6).  Recent data from large scale studies indicate that only a moderate weight loss is sufficient to provide substantial health benefits while lifestyle and diet modification form the basis of all effective strategies for weight reduction, some individuals may need additional intervention like an appropriate use of pharmacotherapy for obesity and cardiometabolic risk. Current medications that have been approved by the BFAD for long term treatment of obesity are sibutramine and orlistat. Orlistat is an enteric lipase inhibitor which impairs the absorption of ingested fats (30%) and thus significantly reduces insulin resistance induced by overfeeding(7). Steatorrhea, bloating and distention, and anal leakage are potential side effects if dietary fat is not restricted (4).  Sibutramine is a centrally acting serotonin and adrenergic reuptake inhibitor(7).Hypertension and increased heart rate are potential complications so it is contraindicated for individuals with known heart disease, uncontrolled hypertension, heart failure, stroke, and arrhythmias (4). Medication combined with lifestyle modification is more effective than placebo with lifestyle modification in promoting weight loss in adults with overweight and obesity.

The weight loss achieved by the subjects enrolled in the phase 2 to 5 were comparable. However, subjects who went beyond phase 5 to 6 showed a significant increase in weight loss from 5.5 to 8.3%. This could be attributed to the extended therapeutic exercises, nutrition counseling, behavioural modification, and use of pharmacotherapeutic agents. Weight management program goals should encompass health improvement and cardiometabolic risk reduction as well as weight loss.

Bioelectric impedance analysis (BIA) used to directly measure the weight and percentage of body fat in the body. The technique measures the resistance of the body to the flow of a safe, low-level electric current through fluids in fat and lean tissues. Lean tissue (muscle) contains abundant water and electrolytes making it conductive. The electrical current passes freely through it. Fat tissue has less water, so the current encounters resistance and flows less easily(7). Body composition analysis of the subjects in the weight management program showed that weight loss was due to loss of body fat rather than body cell mass and total body water. There was a significant decrease in the total body fat in almost all phases of the weight loss program.

Exercise training has been shown to be a powerful strategy for inducing abdominal fat loss particularly to abdomino-visceral fat loss. The more exercise one takes, the greater is the daily energy expenditure and the more rapidly the obesity disappears. Therefore, forced exercise is often an essential part of the treatment for obesity. In a systematic review of prospective randomized weight reduction studies with physical activity measured at baseline, Fogelholm and colleague reported that at a mean 20-month follow-up, the difference between exercise and control groups’ mean weight regain was 1.8kg. Despite the modest effect of physical activity on weight-loss maintenance, they concluded that physical activity should be recommended as one part of a healthful lifestyle(8).

Dietary changes are essential for management of body weight, glycemia, blood lipids, and blood pressure. An energy deficit of 500 to 1,000 calories per day is necessary to achieve a 1 to 2-lb weight loss per week.  The reduction in ingested calories has to be life-long. It is also necessary to modify the whole lifestyle, including eating and exercise patterns. Dietary interventions include regular food intake, reduction in fat intake, change in lifestyle, prevention of dietary lapses, and sufficient intake of low-calorie drinks.


CONCLUSION: | Back

The findings from this study indicate that a non-surgical weight loss program through a multidisciplinary approach can achieve significant weight loss result of 12.7% in one year.

 

ACKNOWLEDGMENT:
We are indebted to the members of the Nutrition Support Team of St Luke’s Medical Center for their help in data gathering and computation of caloric intake, and to the patients and their families for participating in this scientific investigation.

 

REFERENCES: | Back

    1. Fernando R, Llido LO, et al: Prevalence of Malnutrition in a tertiary care hospital im Metro Manila, St. Luke’s Medical Center Journal 1996;3(2): 45-52.
    2. JCAHO Board of Directors, 1995. Comprehensive Accreditation Manual for Hospitals. JCAHO, Chicago,1994.
    3. Jelliffe DB. The Assessment of the Nutritional Status of the Community. WHO Monograph Series 53, Geneva. 1966.
    4. Seagle HM, Strain GW, Makris A, Reeves RS. Position of the American Dietetic Association: Weight Management. J Am Diet Association. 2009; 330-346; 336-337;339.
    5. Curioni CC, Lourenco PM. Long-term weight loss after diet and exercise: A systematic review. Int  J Obesity. 2005;29: 1153-1167
    6. Douketis JD, Macie C, Thabane L, Williamson DF. Systematic review of long term weight  loss studies in obese adults: Clinical significance and applicability to clinical practice. Int J Obesity. 2005;29: 1153-1167
    7. Sobotka L, Allison SP, Furst P, Meier RF, Pertkiewicz M, Soeters PB. Basics in Clinical Nutrition 3rd ed .2004;  10-17; 27-28.
    8. Fogelholm M,Kukkonen-Harjula K. Does physical activity prevent weight gain- A systematic review. Obes Rev. 2000; 95-111.

 

Abstract | Introduction | Methodology | Results | Discussion | References | Back to Articles Page