For patients who must lose
50 pounds or more,
By MARY ANN LITTELL
The holiday season is over, but Christmas cookies and cocktail parties have taken their toll. While losing weight isn't easy for anyone, shedding a few post-holiday pounds is a piece of cake compared to dropping 50, 100 or even 200 pounds.
For the morbidly obese (50 or more pounds overweight), losing weight is more than just being able to fit into a pair of too-tight jeans. It can mean the difference between life and death. A serious weight problem contributes to many chronic, life-threatening conditions, including diabetes, hypertension and coronary artery disease.
Morbid obesity is aptly named. Some studies suggest that excess weight of 100 pounds or more is associated with a six- to twelve-fold increase in mortality rates. Morbid obesity is most prevalent in inner cities, and affects many more women than men. An estimated 55 percent of inner-city women are obese. The ratio of obese women to men is approximately 9 to 1 in urban areas, and 3 to 1 in suburban areas. Ironically, inner cities are the places where people can least afford to participate in weight-loss programs.
For the very overweight, carrot sticks, iceberg lettuce and fat-free salad dressings are not the answer. "Conventional calorie-restricted diets don't usually work with this group," says Marvin Kirschner, MD, professor of medicine at UMDNJ-New Jersey Medical School and chief of endocrinology at UMDNJ-University Hospital (UH). "Ninety percent of them give up because losing the weight takes too long."
Kirschner is also director of the hospital's Metabolic-Nutrition Program, which utilizes a very low calorie, liquid supplement diet to aid weight loss in the morbidly obese. Patients drink the supplements (referred to as shakes because they look and taste like milkshakes) five times a day. They eat no food at all. Intake ranges from 400 to 800 calories a day, depending on gender and how much weight the patient needs to lose.
Optifast is the supplement of choice for the program. "Many liquid supplements are very low in protein, which isn't good when you're on such a restrictive diet," says Kirschner. "We use Optifast because it contains top-quality protein in more than adequate amounts."
The program treats approximately 200 patients a year. Through a grant from the Health Care Foundation of New Jersey, Kirschner has been able to expand the program to include more inner city residents, who may attend at no cost. To recruit patients, Kirschner sent letters to primary care physicians in Newark and the surrounding areas, asking for referrals. Some 130 inner-city residents now participate; the rest of the patients are suburban.
The average patient loses 20 to 25 pounds the first month. Losses of 100 pounds in six months are not unusual. Over the long term, 50 percent of patients are able to maintain some or all of their weight loss, 25 percent go back to their starting weight, and the remaining 25 percent get heavier. "To successfully keep weight off, people have to learn new eating habits," he says. "Some are not able to do that."
Kirschner should know. For the past 22 years he has studied the effects of low-calorie dietary supplements on obesity and weight loss. Such diets are obviously not for everyone. "Compliance is a continuing problem," says Kirschner. "Many patients find it too hard to give up food completely. So they eat regular food along with their Optifast, and then don't lose weight." Some patients, such as 42-year-old Jacqueline Boulware of East Orange, welcome not having to make decisions about what foods to eat. The mother of three entered the program weighing 379 pounds. In five weeks she lost 33 pounds, and hopes to lose 150 to 200 more. "I cook for my family every night, but I don't eat anything," she says. "They eat their dinner and I drink my shakes. They taste pretty good, and fill me up so I'm not tempted to cheat."
Weekly meetings with dietitians teach patients healthier ways of eating. As a result, Boulware says she has changed her shopping and cooking habits. "I don't buy as many sweets as I used to," she says. "I also broil, bake or boil foods, rather than frying them, and serve more vegetables and salads."
Nutrition education is just one component of the program. At the weekly meetings, patients meet with a team that includes primary care physicians, social workers and psychiatrists. At group sessions, patients share their experiences. Their weight, blood pressure, and blood chemistry are monitored.
In a supplemental study, Kirschner is also monitoring serum leptin levels in patients. Leptin, often called the obesity hormone because it is produced by fat cells, is found in higher concentrations in obese patients. Preliminary findings indicate a drop in serum leptin levels as patients lose weight. The role of leptin in controlling eating and hunger is being closely studied.
Patients do not necessarily have to reach their ideal weight to make significant improvements in their health, says Kirschner. Losing just 10 percent of the starting weight reduces blood pressure, cholesterol and sleep apnea, a potentially serious problem in the obese. "We encourage setting a 10 percent weight loss as a first goal," says Kirschner. "It's a realistic, attainable goal, even for someone who weighs 300 pounds."
While the dropout rate is a relatively high 25 percent, the patients who remain in the program are enthusiastic about its results. Seventy-three-year-old William Drejka, of Cranford, NJ, came to the center in mid-April weighing 315 pounds. So far, he has lost 51 pounds. His goal is to lose at least 50 more. "It's hard to keep to this diet, because I like to eat," he says. "But I feel so much better than I did when I was heavier." Kirschner relates that Drejka's sleep apnea is now gone as a result of his weight loss.
Once patients on the liquid supplement diet lose weight, the battle is not over. Maintaining weight loss requires vigilance on the part of the patient, but the health benefits are well worth the effort. Eating patterns do change, but it doesn't happen overnight. Jacqueline Boulware is willing to be patient: "It took me 42 years to get this big. I'll invest whatever time it takes to lose this weight and keep it off."
For more information about the Metabolic-Nutrition program, call 973-972-0791.
1999 Table of Contents
The magazine of the University of Medicine and Dentistry of New Jersey