EFFICACIA DELLE STRATEGIE PER LA PROMOZIONE DEL CALO PONDERALE A LUNGO TERMINE Giorgio Bedogni Obiettivo Discutere l evidenza di efficacia e sicurezza delle strategie per l ottenimento di un calo ponderale a lungo termine Unità di Epidemiologia Clinica Centro Studi Fegato Basovizza (TS) Evidence-based practice Posizione ADA 2009 Haynes RB. ACP Journal Club 2002;136:A11
Classificazione dell evidenza A. Grade B. Strength C. Recommendation I = Good Strong Conditional II = Fair Fair Imperative III = Limited Weak IV = Expert Opinion Consensus V = Not assignable Insufficient evidence Seagle et al. JADA 2009;109:330 Posizione Obiettivi It is the position of the ADA that successful weight loss management to improve overall health for adults require a lifelong commitment to healthful lifestyle behaviors emphasizing sustainable and enjoyable eating practices and daily physical activity Seagle et al. JADA 2009;109:330 1.! Prevenzione o arresto dell incremento ponderale 2.! Promozione di calo ponderale di piccola o grande entità (purché mantenibile) attraverso modificazione dell alimentazione e dell attività fisica 3.! Miglioramento della salute fisica ed emozionale 4.! Miglioramento del comportamento relativo all alimentazione e all attività fisica Seagle et al. JADA 2009;109:331
Nutrition care process The Nutrition Care Process and Model (NCPM) is a systematic problem-solving method that food and nutrition professionals use to think critically and make decisions that address practice-related problems Lacey K et al. JADA. 2003;103:1061. ADA NCP Writing Group JADA 2008;108:1113. BMI e circonferenza vita BMI and waist circumference should be used to classify overweight and obesity, estimate risk for disease, and to identify treatment options Rating: FAIR, IMPERATIVE Seagle et al. JADA 2009;109:332
Approcci disponibili 1.! Composizione della dieta 2.! Controllo delle porzioni 3.! 4.! Pasti sostitutivi 5.! 6.! 7.! 8.! Farmacoterapia 9.! Seagle et al. JADA 2009;109:332 Composizione della dieta Energia 1.! Composizione della dieta 2.! Controllo delle porzioni 3.! 4.! Pasti sostitutivi 5.! 6.! 7.! 8.! Farmacoterapia 9.! Reducing dietary fat and/or carbohydrates is a practical way to create a caloric deficit of 500 to 1000 kcal below estimated energy needs and should result in a weight loss of 1 to 2 lb per week Rating: STRONG, IMPERATIVE Seagle et al. JADA 2009;109:334
Carboidrati Carboidrati...Consumption of a low-carbohydrate diet is associated with a greater weight and fat loss than traditional reduced-calorie diet during the first 6 months, but these differences are not significant after 1 year Rating: FAIR, CONDITIONAL...The safety has not been evaluated for long-term extreme restrictions of carbohydrates (<35% of energy from carbohydrates) Seagle et al. JADA 2009;109:334 Seagle et al. JADA 2009;109:334 Low-carb vs. low-fat Low-carb vs. low-fat
DIRECT DIRECT Shai et al. New Engl J Med 2008;359:229 DIRECT DIRECT The more favorable effects on lipids (with the lowcarbohydrate diet) and on glycemic control (with the Mediterranean diet) suggests that personal preferences might inform individual tailoring of dietary interventions Shai et al. New Engl J Med 2008;359:229 Shai et al. New Engl J Med 2008;359:229
WHI Aumento delle HDL e rischio cardiovascolare: nessun effetto Aumento delle HDL e rischio cardiovascolare: nessun effetto Indice glicemico A low glycemic index diet is not recommended for weight loss or weight maintenance as part of a comprehensive weight management program since it has not been shown to be effective in these areas Rating: STRONG, IMPERATIVE Seagle et al. JADA 2009;109:334
Latte e derivati Calcio In order to meet nutritional recommendations, incorporate 3-4 servings of low-fat dairy foods a day as part of a comprehensive weight management program Rating: FAIR, IMPERATIVE Seagle et al. JADA 2009;109:334 Research suggests that calcium intake lower than the recommended intake is associated with increased body weight [OSSERVAZIONALE] However, the effect of dairy and/or calcium at above recommended levels on calcium management is unclear [SPERIMENTALE] Seagle et al. JADA 2009;109:334 Controllo delle porzioni 1.! Composizione della dieta 2.! Controllo delle porzioni 3.! 4.! Pasti sostitutivi 5.! 6.! 7.! 8.! Farmacoterapia 9.!
Controllo delle porzioni Portion control should be included as part of comprehensive weight management program. Portion controls at meals and snacks results in reduced energy intake and weight loss Rating: FAIR, IMPERATIVE Seagle et al. JADA 2009;109:334 Composizione della dieta Controllo delle porzioni Pasti sostitutivi Farmacoterapia Pasti sostitutivi Total caloric intake should be distributed throughout the day, with the consumption of four to five meals/ snacks including breakfast. Consumption of greater energy intake during the day may be preferable to evening consumption Rating: FAIR, IMPERATIVE Seagle et al. JADA 2009;109:334 Composizione della dieta Controllo delle porzioni Pasti sostitutivi Farmacoterapia
Pasti sostitutivi For people who have difficulty with self-selection and/or portion control, meal replacements may be used as part of the diet component of a comprehensive weight management program Rating: STRONG, CONDITIONAL Seagle et al. JADA 2009;109:335 Composizione della dieta Controllo delle porzioni Pasti sostitutivi Farmacoterapia (< 800 kcal) Results in significant weight loss (Grade I = Good) Results in significantly greater weight loss than reduce-calorie diets (Grade I = Good) Studies report varying levels of weight regain based on difference in weight management strategies (Grade I = Good) Seagle et al. JADA 2009;109:335 Composizione della dieta Controllo delle porzioni Pasti sostitutivi Farmacoterapia
Despite its modest impact on weight loss, physical activity is important for improving health-related outcomes Seagle et al. JADA 2009;109:336 Quale e quanta attività fisica? Evidenza Obiettivo Riduzione del rischio di malattia cronica Ottenimento di calo ponderale Mantenimento di calco ponderale Indicazione 30 minuti di attività fisica moderata per la maggioranza dei giorni della settimana [!4-5] 60 minuti di attività fisica moderatavigorosa per la maggioranza dei giorni della settimana [!4-5] 60-90 minuti di attività fisica moderata-vigorosa tutti i giorni della settimana L attività fisica ha un chiaro effetto protettivo nei confronti della mortalità [OSSERVAZIONALE] Inoltre, il principale determinante del successo nel mantenimento del calo ponderale è il mantenimento di un attività fisica regolare [OSSERVAZIONALE] Seagle et al. JADA 2009;109:336 Seagle et al. JADA 2009;109:336
Composizione della dieta Controllo delle porzioni Pasti sostitutivi Farmacoterapia A comprehensive weight management program should make maximum use of the multiple strategies for behavioral therapy (i.e. self-monitoring, stress management, stimulus control, contingency management, cognitive restructuring and social support Seagle et al. JADA 2009;109:339 Cognitive behavior therapy in addition to diet and physical activity leads to additional weight loss. Continued behavioral interventions may be necessary to prevent a return to baseline weight Rating: STRONG, IMPERATIVE It is possible that there is no single behavioral tool that works best. Instead it may be more important to match behavioral tools with each individual s unique set of characteristics. These are the type of questions than need further attention and research. Seagle et al. JADA 2009;109:339 Seagle et al. JADA 2009;109:339
Farmacoterapia Farmacoterapia Composizione della dieta Controllo delle porzioni Pasti sostitutivi Farmacoterapia FDA-approved weight loss medications may be part of a comprehensive weight management program. Research indicates that pharmacotherapy may enhance weight loss in some overweight and obese adults Rating: STRONG, IMPERATIVE Seagle et al. JADA 2009;109:339 2009: ritiro del rimonabant (Europa) 2010: ritiro della sibutramina (Europa) The Committee confirmed that the risk of psychiatric side effects, including depression, sleep disorders, anxiety and aggression, is approximately doubled in patients taking Acomplia, compared to obese or overweight patients taking placebo (a dummy treatment). The new data from ongoing studies and post-marketing reports indicated that serious psychiatric disorders may be more common than in the clinical trials used in the initial assessment of the medicine The SCOUT study showed an increased risk of serious cardiovascular events (such as heart attack or stroke) in patients with known cardiovascular disease taking sibutramine http://www.ema.europa.eu/pdfs/human/referral/sibutramine Sibutramine_Q&A_80817909en.pdf http://www.ema.europa.eu/humandocs/pdfs/epar/acomplia/53715308en.pdf
2010: ritiro della sibutramina (Europa) 2010: ritiro della sibutramina (Europa) Most of the patients in the SCOUT study would not normally be given sibutramine, as the medicine is contra-indicated in patients with cardiovascular disease. Nevertheless the Committed considered that an increased risk can also apply to patients for whom sibutramine can be prescribed because obese and overweight patients are likely to be at risk of cardiovascular disease Finally, looking at all of the studies of sibutramine in the management of obesity, the weight loss achieved with sibutramine treatment is modest in comparison with that obtained with placebo, with patients losing on average two to four kilograms more than with placebo. The Committee also noted that it is not clear if this effect on weight loss can be maintained when sibutramine treatment is stopped. http://www.ema.europa.eu/pdfs/human/referral/sibutramine Sibutramine_Q&A_80817909en.pdf http://www.ema.europa.eu/pdfs/human/referral/sibutramine Sibutramine_Q&A_80817909en.pdf Composizione della dieta Controllo delle porzioni Pasti sostitutivi Farmacoterapia Dietitians should collaborate with other members of the health care team regarding the appropriateness of bariatric surgery for people who have not achieved weight loss goals with less invasive weight loss methods and who meet the NHLBI criteria Rating: STRONG, IMPERATIVE Seagle et al. JADA 2009;109:339
Per concludere Posizione ADA It is the position of the ADA that successful weight loss management to improve overall health for adults require a lifelong commitment to healthful lifestyle behaviors emphasizing sustainable and enjoyable eating practices and daily physical activity Seagle et al. JADA 2009;109:330 Centralità del paziente Approccio interdisciplinare The partnership between RDs and their patients should focus on developing strategies that will enhance opportunities for clients to control their own behaviors related to overweight or obesity Seagle et al. JADA 2009;109:330 If RDs work only with physicians or a team that includes a coordinated group of health professionals with a variety of skills, they should work effectively with the team to achieve the best outcome for the patient Seagle et al. JADA 2009;109:330
Evidence-based practice Grazie Haynes RB. ACP Journal Club 2002;136:A11