Treatment of obesity
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Treatment of Obesity. Pennington Biomedical Research Center Division of Education. Treatment options. When does obesity threaten the health and life of a patient? Which patients have co-morbidities that make an aggressive treatment necessary? . Steps in determining treatment.

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Treatment of obesity l.jpg

Treatment of Obesity

Pennington Biomedical Research Center

Division of Education


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Treatment options

  • When does obesity threaten the health and life of a patient?

  • Which patients have co-morbidities that make an aggressive treatment necessary?

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Steps in determining treatment

  • Determine BMI.

  • Assess complications and risk factors

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Steps in determining treatment

  • Determine BMI-related health risk

  • Determine weight reduction exclusions

    • Mental illness

    • Unstable medical condition

    • Some medications

    • Temporary

      • Pregnancy or lactation

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Steps in determining treatment

  • Possible exclusions

    • Osteoporosis

    • BMI in minimal or no-risk category

    • History of mental illness

    • Medications

  • Permanent exclusions

    • Anorexia nervosa

    • Terminal illness

  • Assess patient readiness

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Steps in determining treatment

Treatment Options

1. Mild energy-deficit regimen

Diet, diet and exercise, behavioral therapy

2. Aggressive energy-deficit regimen

VLCD

Extensive exercise program

3. Obesity drugs

4. Surgery

More extreme options

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Dietary treatment

When someone is a few pounds overweight and is motivated to lose weight, dietary approach is a safe and effective method for weight loss. It is also the best method for helping to acquire new skills for maintaining a weight loss.

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Dieting with the Exchange List

  • The Exchange diet.

  • Monitor intake of carbohydrates, fat and protein as well as portion sizes.

  • Includes foods from each group and can be used indefinitely.

  • It also works well in weight maintenance.

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Dieting with the Exchange List

Food is broken down into 6 categories:

Starch/Bread

Meat

Vegetables

Fruit

Milk

Fat

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The Exchange List

  • The number of exchanges is determined by the total number of calories required.

  • Different for each person and depends on:

    • height, weight, and energy expenditure.

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Example of daily exchange diet 1800 kcals daily l.jpg

1 c orange juice

2 slices of toast

1 hard-cooked egg

2 tsp margarine

1 c 2% milk

Coffee or tea

2 Fruits

2 Breads

1 Meat

2 Fat

1 Milk

Free Food

Example of daily exchange diet: 1800 Kcals daily

BREAKFAST

Yields

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½ c tuna

2 slices whole wheat bread

½ c tomato slices

Lettuce/cucumber salad

1 c sliced peaches

1 tsp margarine

Tea with lemon

2 Meat

2 Bread

1 Vegetable

Raw Vegetable

2 Fruit

2 Fat

Free Foods

Example of daily exchange diet: 1800 Kcals daily

LUNCH

Yields

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3 oz baked chicken

½ c mashed potato

1 small whole grain roll

½ c broccoli, ½ c carrots

Tossed salad

1 Tbsp salad dressing

1 tsp margarine

Coffee

3 meat

1 Bread

1 Bread

1 Vegetable

Raw Vegetable

1 Fat

1 Fat

Free Food

Example of daily exchange diet: 1800 Kcals daily

DINNER

Yields

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2 graham crackers

1 c 2% milk

1 Bread

1 Milk

Example of daily exchange diet: 1800 Kcals daily

EVENING SNACK

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The Exchange Diet

For more information please visit:

http://www.diabetes.org/home.jsp

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Dieting Using Calorie Controlled Portions

MEAL REPLACEMENT PLAN

  • Liquid formula or a packaged item

    • Fixed number of calories to replace a meal.

  • Control portion sizes

    • Fat, carbohydrate, calories

  • Balanced meals

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Meal Replacement Plan

4 types of meal replacers:

Powder mixes

Shakes

Bars

Prepackaged Meals

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Meal Replacement Plan

An intake of five fruits and vegetables is recommended.

  • Effective

  • Convenient

  • Nutritionally balanced

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Example:A MEAL REPLACEMENT PLAN

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Exercise

  • Adults: 30-45 minutes of exercise three to five days each week

  • Include 5-10 minute warm up and cool down

  • Weight loss: at least 30 minutes of aerobic activity a day for five days

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Exercise

  • Children: at least 60 minutes, and up to several hours of physical activity per day for children and adolescents

  • Several bouts of physical activity lasting 15 minutes or more each day

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Exercise

Energy Balance = maintaining weight.

Positive energy balance leads to weight gain.

Negative energy balance leads to weight loss.

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Exercise: Benefits

Exercise builds lean body mass.

Walking, running and doing physical activity can burn two to three times more calories than similar amount of time sitting.

With exercise there is an improvement in overall physical fitness.

Exercise improves maintenance of weight after weight loss.

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Exercise

For Weight Loss

  • 150 to 200 minutes of moderate physical activity each week

  • diet for weight loss

    For Improved Health

    An exercise programwith less than 150 minutes a week and lower intensity can result in improvement in cardio-respiratory fitness.

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Aerobic Activity

Aerobic exercise is any extended activity that makes the lungs and heart work harder while using the large muscle groups in the arms and legs at a regular, even pace.

EXAMPLES 

Brisk walking

Jogging

Bicycling

Swimming

Aerobic dancing

Racket sports

Lawn mowing

Ice or roller skating

Using aerobic equipment

(treadmill, stationary bike)

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Anaerobic Activity

Anaerobic activity is short bursts of very strenuous activity using large muscle groups

(Ex: weight lifting, curls, power lifting).

Helps build and tone muscles, but it does not benefit the heart or the lungs.

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Very Low Calorie Diets (VLCD)

  • Formula diet of 800 calories or less.

  • Must be under proper medical supervision.

  • Produce significant weight loss in moderately to severely obese patients.

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VLCD: Facts

  • Not recommended for pregnant or breastfeeding women

  • Not appropriate for children or adolescents

  • Not recommended for older individuals

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Behavioral Treatment

  • Widely used strategy

  • Based on adjusting energy balance

  • Individual treatment, or

  • Group Format

    • (Around 18-24 weeks)

  • One of the most successful treatment programs

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Group Approaches

  • Social support

    • integration into social network and positive

      interactions with others.

    • Individual feels support, acceptance, and encouragement by others.

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Behavior Treatment

  • Need to change one’s approach

    • thinking

    • feelings

    • actions

      to eating and physical activity.

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Behavioral targets

Total energy

intake

Total energy

expenditure

_

Weight

=

Eating

Activity

Targets of behavioral therapy

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Behavior Therapy: Important Components

  • Making Lifestyle Change a Priority

  • Establishing a Plan for Success

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Behavior Therapy: Important Components

3.Setting Goals

  • Calories, fat, physical activity.

  • Short-term goal of losing 1 to 2 pounds a week.

  • Choosespecific, attainable, and realistic goals.

  • Have a long-term goal.

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Behavior Therapy: Important Concepts

4. Keeping Track of Eating and Exercising

  • Tracking to raise awareness.

  • Self monitoring.

  • Record time, activating event, place and quantity of eating, and activity behaviors.

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Behavior Therapy: Important Concepts

5. Avoiding a Food Chain Reaction

  • Stimulus control.

  • Learning to recognize cues.

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Behavior Therapy: Important Concepts

Techniques to conquer eating triggers include:

  • eating regular meals

  • eating at the same time and place

  • use smaller plates

  • keeping accessible food out of sight

  • eating only when hungry

  • avoiding activities that encourage eating

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Behavior Therapy: Important Concepts

6. Changing Eating and Activity Patterns

  • slowing pace of eating

  • reducing portion sizes

  • measuring food intake

  • leaving food on plate

  • improving food choices

  • eliminating second servings

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Behavior Therapy: Important Concepts

Changing Eating and Activity Patterns

  • Programmed exercise vs lifestyle

    • Lifestyle activity preferable for weight loss.

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Behavior Therapy: Important Concepts

7. Contingency Management

  • Positive reinforcement (reward)

    • An effective reward - immediate, desirable, and given based on meeting a specific goal.

    • Tangible rewards - a new CD

    • Intangible reward – taking time off

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Behavior Therapy: Important Concepts

8. Cognitive Behavioral Strategies

  • Traditional behavioral treatment components with emphasis on thinking patterns that may affect eating behaviors.

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Behavior Therapy: Important Concepts

9. Stress Management

  • Stress is a primary predictor of overeating and relapse.

  • Stress management skills

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Drug Treatment of Obesity:Indicated when

  • BMI is greater than 30

  • BMI is higher than 27 and there are other cardiovascular complications

  • After several attempts diet alone is not enough

Cardiovascular complications include: Hypertension, Dyslipidemia, Coronary Heart Disease, Type 2 Diabetes, and Sleep Apnea

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Drug Therapy

Commonly prescribed drugs for the treatment of obesity include:

Phentermine

Sibutramine

Orlistat

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Drug Therapy: Phentermine

Brand names are Adipex-P, Obenix, Oby-Trim

Most commonly prescribed medication for weight loss.

Phentermine increases norepinephrine, a neurotransmitter in the brain that decreases appetite.

Phentermine has stimulant properties, and it may cause high blood pressure or irregular heat beats.

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Drug Therapy: Sibutramine

The brand name is Meridia

Sibutramine induces weight loss by reducing food intake.

It stimulates the

satiety centers in the brain.

Sibutramine use may increase heart rate and blood pressure.

Sibutramine is not recommended for someone with uncontrolled hypertension, tachycardia, or serious heart, liver, or kidney disease.

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Drug Therapy:Orlistat

The Brand name is Xenical

Orlistat prevents the digestion of dietary fat.

Bowel habits will likely change.

Leads to improvement in blood lipids.

Multivitamin supplement is encouraged.

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Surgical Treatment of Obesity

Criteria used for surgical treatment:

  • BMI is 40 or higher

  • BMI of 35-39.9 and a serious obesity-related health problem

    such as: Type 2 diabetes, hypertension, heart disease, or sleep apnea

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Types of GI surgeries available

Restrictive

Malabsorptive

Combined restrictive/malabsorptive

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GI Surgeries: Restrictive

Purely restrictive operations only limit food intake and do not interfere with the normal digestive process.

Create a pouch.

Delay in food emptying.

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Restrictive Operations: Examples

  • Adjustable gastric banding

    A band is clamped to create a pouch.

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Restrictive Operations: Examples

2. Vertical banded gastroplasty.

Uses the band and staples to create

a small pouch. Not commonly used

today.

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Restrictive Operations: Advantages

  • Generally safer than malabsorptive procedures.

  • Done via laparoscopy allowing for smaller incisions.

  • Surgeries can be reversed if necessary.

  • Result in few nutritional deficiencies.

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Restrictive Operations: Disadvantages

  • Smaller weight loss.

  • Can lead to weight gain over time.

  • No change in eating habits.

  • Success depends on the patient’s willingness to adopt a healthy lifestyle.

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Restrictive Operations: Risks

  • Overeating leading to vomiting.

  • Break in tubing.

  • Problems leading to a second operation.

    These risks need to be taken into account by any individual considering the surgery!

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Malabsorptive Operations

  • The main malabsorptive operation is the jejunoileal bypass which is not performed today because of the high incidence of health complications.

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Combined Restrictive and Malabsorptive Operations

Restricts both food intake and the amount of calories and nutrients the body absorbs.

Roux-en-Y gastric bypass (RGB)

Creates a pouch.

Connects the small intestine

to the pouch, bypassing large

sections of the intestines.

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Combined Restrictive and Malabsorptive Operations

Biliopancreatic diversion (BPD)

Remove portion of stomach.

Connect this directly to the

final segment of the small intestine

completely bypassing sections of

intestines.

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Combined Operations: Advantages

  • Rapid weight loss.

  • Maintain good weight loss for 10 years or more.

  • Can lose up to 75-80% of excess weight.

  • May lead to greater improvement in health.

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Combined Operations: Disadvantages

  • Can be difficult.

  • May result in long-term nutritional deficiencies.

  • Decreased absorption of iron and calcium.

  • Require fat soluble vitamin supplementation.

  • May have dumping syndrome.

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Combined Operations: Risks

  • May lead to complications.

  • Greater risk for abdominal hernias.

  • The risk of death may be higher.

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Bariatric Surgery: Facts

Procedures cost from $20,000 to $35,000.

Medical insurance coverage varies by state.

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NIDDK(National Institute of Diabetes and Digestive and Kidney Diseases)

The patient should consider the following questions prior to weight loss surgery:

  • Are you unlikely to lose weight or keep weight off long-term with non-surgical measures?

  • Are you well informed about the surgical procedure and the effects of treatment?

  • Are you determined to lose weight and improve your health?

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NIDDK

4. Are you aware of how your life may change after the operation?

5. Are you aware of the potential for serious complications, dietary restrictions, and occasional failures?

6. Are you committed to lifelong medical follow-up and vitamin/mineral supplementation?

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Conclusions

  • When there are no complications or co-morbidities associated with obesity, dietary, exercise and behavioral approaches are the safest and best approaches.

  • For successful weight loss to become permanent, an individual has to adopt new behaviors to maintain weight loss.

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Conclusion

  • It is very important for individuals considering initiation of weight loss drug therapy or surgeries to be well aware of the risks associated with the treatments.

  • Once all risks are understood, then ultimately it is the individual’s decision to go along with the treatment or not.

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References: Behavior Therapy and VLCD Information

  • http://www.medhelp.org/NIHlib/GF-390.html

  • Foreyt, J.P., & Poston, W.S.C., Jr. (1998a). The role of the behavioral counselor in obesity treatment. J Am Diet Assoc, 10(Supplement 2), S27-S30

  • Foreyt, J.P., & Poston, W.S.C., Jr. (1998b). What is the role of cognitive-behavior therapy in patient management? Obes Res, 6(Supplement 1), 18S-22S

  • Foster, G.D., Wadden, T.A., Vogt, R.A., & Brewer, G. (1997). What is a reasonable weight loss? Patients' expectations and evaluations of obesity treatment outcomes. J Consult Clin Psychol, 65, 79-85

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References : Behavior therapy

  • Poston, W.S.C., Jr., Hyder, M.L., O'Byrne, K.K., & Foreyt, J.P. (2000). Where do diets, exercise, and behavior modification fit in the treatment of obesity? Endocrine, 13(2), 187-192.

  • Wadden, T.A., Sarwer, D.B., & Berkowitz, R.I. (1999). Behavioural treatment of the overweight patient. Baillieres Best Pract Res Clin Endocrinol Metab, 13(1), 93-107.

  • Wing, R.R. (1993). Behavioral approaches to the treatment of obesity. In G. Bray, C. Bouchard & P. James (Eds.), Handbook of Obesity (pp. 855-873). New York: Marcel Dekker, Inc.

  • Wing, R.R., & Tate, D.F. (2002). Behavior modification for obesity. In J.F. Caro (Ed.), Obesity. http://www.endotext.org/obesity/index.htm:

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Sites: Drug Therapy Info & Surgery

  • http://www.cdc.gov

  • National Heart, Lung, and Blood Institute, Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, 1998.

  • Astrup A, Hansen DL, Lundsgaard C, Toubro S. Sibutramine and energy balance. Int J ObesRelatMetabDisord 1998 Aug; 22 Suppl 1: S30-S35.

  • Bray GA, Ryan DH, Gordon D, et al. A double-blind randomized placebo-controlled trial of sibutramine. Obes Res 1996 May; 4(3): 263-70.

  • Heal DJ, Aspley S, Prow MR, et al. Sibutramine: a novel anti-obesity drug. A review of the pharmacological evidence to differentiate it from d-amphetamine and d-fenfluramine. Int J ObesRelatMetabDisord 1998 Aug; 22 Suppl 1: S18-S29.

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References: Drug therapy & Surgery

  • www.meridia.net

  • Waitman, JA, Aronne LJ. Phrmacotherpay of obesity. Obesity Management 1: 15-19, 2005.

  • Greenway, F. Surgery for obesity. Endocrinology and Metabolism Clinics of North America 25(4):1005-1027.

  • Surgery for morbid obesity: What patients should know. 3rd Ed. American Society for BariatricSurgery, Gainesville, FL 2001.

  • http://win.niddk.nih.gov/publications/gastric.htm

  • Escott-Stump, S. Nutrition and Diagnosis-Related Care. 5th Edition. 2002.

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References: Exercise

  • http://www.cdc.gov

  • Ross R, Jansses I, Dawson J, Kungl A-M, Kuk JL, Wong SL, Nguyen-Day T-B, Lee SL, Kilpatrick K, Hudson R. Exercise induced reduction in obesity and insulin resistance in women: a randomized controlled trial. Obesity Research 12:789-798, 2004.

  • Jakicic JM, Marcus BH, Gallagher KI, Napolitano M, Lang W. Effects of exercise duration and intensity on weight loss in overweight, sedentary women. JAMA 10: 1323-1330, 2003.

  • Ross R, Katzmarzyk PT. Cardio respiratory fitness is associated with diminished total and abdominal obesity independent of body mass index. International Journal of Obesity 27: 204-210, 2003.

  • McArdle WD, Katch FL, and Katch VL. Exercise Physiology: Energy, Nutrition and Human Performance, 5th Edition. Lippincott Williams & Wilkins 2004.

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References: Diet

  • http://www.cdc.gov

  • Noakes M, Foster PR, Keogh JB, Clifton PM. Meal replacements are as effective as structured weight-loss diets for treating obesity in adults with features of metabolic syndrome. J Nutr. 2004 Aug;134(8):1894-9.

  • Truby H, Millward D, Morgan L, Fox K, Livingstone MB, DeLooy A, Macdonald I. A randomised controlled trial of 4 different commercial weight loss programmes in the UK in obese adults: body composition changes over 6 months.Asia Pac J ClinNutr. 2004 Aug;13(Suppl):S146.

  • http://www.slim-fast.com/plan/index.asp?bhcp=1 Accessed September 16, 2004.

  • Halford JCG, Ball MF, Pontin EE, Maharjan LB, Dovey TM, Pinkney JH, Wilding JPH, Mela DJ. The impact of using meal-replacements versus standard dietetic advice on body weight, appetite, mood, and satisfaction during a 12-week weight control. North American Association for the Study of Obesity Conference, November 14-18, 2004, Las Vegas, Nevada.

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Pennington Biomedical Research CenterDivision of Education

  • Heli J. Roy, PhD, RD

  • Beth Kalicki

  • Division of EducationPhillip Brantley, PhD, DirectorPennington Biomedical Research CenterClaude Bouchard, PhD, Executive Director

Edited: October 2009

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About Our Company…

ThePennington Biomedical Research Center is a world-renowned nutrition research center.

Mission:

To promote healthier lives through research and education in nutrition and preventive medicine.

The Pennington Center has several research areas, including:

Clinical Obesity Research

Experimental Obesity

Functional Foods

Health and Performance Enhancement

Nutrition and Chronic Diseases

Nutrition and the Brain

Dementia, Alzheimer’s and healthy aging

Diet, exercise, weight loss and weight loss maintenance

The research fostered in these areas can have a profound impact on healthy living and on the prevention of common chronic diseases, such as heart disease, cancer, diabetes, hypertension and osteoporosis.

The Division of Education provides education and information to the scientific community and the public about research findings, training programs and research areas, and coordinates educational events for the public on various health issues.

We invite people of all ages and backgrounds to participate in the exciting research studies being conducted at the Pennington  Center in Baton Rouge, Louisiana. If you would like to take part, visit the clinical trials web page at www.pbrc.edu or call (225) 763-3000.

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