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11 Case Study: Can We Reduce Obesity by Encouraging People to Eat Healthy Food?

• Published: June 2016
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In the United States, an estimated 17% of children age 2 to 19 years are considered obese; 32% are overweight. Worldwide, 12.9% to 23.8% of children are obese, and the prevalence is increasing. Preventing the onset of obesity remains a critical public health goal of the next decade. Population health science approaches to reducing the prevalence of obesity are presented: one that focuses on coaching individuals to change their behaviors related to food and exercise, and another that focuses on changing the food environment (ubiquitous exposure). An illustration is provided of how to conceptualize the limits of individual-level behavioral interventions on the population distributions of obesity incidence using basic assumptions and data simulation. The effect of individual motivation to prevent obesity is bounded by the prevalence of unhealthy environments in which children are living, which affects the number of incident obesity cases observed and the proportion attributable to individual determinants.

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• Published: 21 June 2021

The lived experience of people with obesity: study protocol for a systematic review and synthesis of qualitative studies

• Emma Farrell   ORCID: orcid.org/0000-0002-7780-9428 1 ,
• Marta Bustillo 2 ,
• Carel W. le Roux 3 ,
• Joe Nadglowski 4 ,
• Eva Hollmann 1 &
• Deirdre McGillicuddy 1  

Systematic Reviews volume  10 , Article number:  181 ( 2021 ) Cite this article

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Obesity is a prevalent, complex, progressive and relapsing chronic disease characterised by abnormal or excessive body fat that impairs health and quality of life. It affects more than 650 million adults worldwide and is associated with a range of health complications. Qualitative research plays a key role in understanding patient experiences and the factors that facilitate or hinder the effectiveness of health interventions. This review aims to systematically locate, assess and synthesise qualitative studies in order to develop a more comprehensive understanding of the lived experience of people with obesity.

This is a protocol for a qualitative evidence synthesis of the lived experience of people with obesity. A defined search strategy will be employed in conducting a comprehensive literature search of the following databases: PubMed, Embase, PsycInfo, PsycArticles and Dimensions (from 2011 onwards). Qualitative studies focusing on the lived experience of adults with obesity (BMI >30) will be included. Two reviewers will independently screen all citations, abstracts and full-text articles and abstract data. The quality of included studies will be appraised using the critical appraisal skills programme (CASP) criteria. Thematic synthesis will be conducted on all of the included studies. Confidence in the review findings will be assessed using GRADE CERQual.

The findings from this synthesis will be used to inform the EU Innovative Medicines Initiative (IMI)-funded SOPHIA (Stratification of Obesity Phenotypes to Optimize Future Obesity Therapy) study. The objective of SOPHIA is to optimise future obesity treatment and stimulate a new narrative, understanding and vocabulary around obesity as a set of complex and chronic diseases. The findings will also be useful to health care providers and policy makers who seek to understand the experience of those with obesity.

Systematic review registration

PROSPERO CRD42020214560 .

Peer Review reports

Obesity is a complex chronic disease in which abnormal or excess body fat (adiposity) impairs health and quality of life, increases the risk of long-term medical complications and reduces lifespan [ 1 ]. Operationally defined in epidemiological and population studies as a body mass index (BMI) greater than or equal to 30, obesity affects more than 650 million adults worldwide [ 2 ]. Its prevalence has almost tripled between 1975 and 2016, and, globally, there are now more people with obesity than people classified as underweight [ 2 ].

Obesity is caused by the complex interplay of multiple genetic, metabolic, behavioural and environmental factors, with the latter thought to be the proximate factor which enabled the substantial rise in the prevalence of obesity in recent decades [ 3 , 4 ]. This increased prevalence has resulted in obesity becoming a major public health issue with a resulting growth in health care and economic costs [ 5 , 6 ]. At a population level, health complications from excess body fat increase as BMI increases [ 7 ]. At the individual level, health complications occur due to a variety of factors such as distribution of adiposity, environment, genetic, biologic and socioeconomic factors [ 8 ]. These health complications include type 2 diabetes [ 9 ], gallbladder disease [ 10 ] and non-alcoholic fatty liver disease [ 11 ]. Excess body fat can also place an individual at increased cardiometabolic and cancer risk [ 12 , 13 , 14 ] with an estimated 20% of all cancers attributed to obesity [ 15 ].

Although first recognised as a disease by the American Medical Association in 2013 [ 16 ], the dominant cultural narrative continues to present obesity as a failure of willpower. People with obesity are positioned as personally responsible for their weight. This, combined with the moralisation of health behaviours and the widespread association between thinness, self-control and success, has resulted in those who fail to live up to this cultural ideal being subject to weight bias, stigma and discrimination [ 17 , 18 , 19 ]. Weight bias, stigma and discrimination have been found to contribute, independent of weight or BMI, to increased morbidity or mortality [ 20 ].

Thomas et al. [ 21 ] highlighted, more than a decade ago, the need to rethink how we approach obesity so as not to perpetuate damaging stereotypes at a societal level. Obesity research then, as now, largely focused on measurable outcomes and quantifiable terms such as body mass index [ 22 , 23 ]. Qualitative research approaches play a key role in understanding patient experiences, how factors facilitate or hinder the effectiveness of interventions and how the processes of interventions are perceived and implemented by users [ 24 ]. Studies adopting qualitative approaches have been shown to deliver a greater depth of understanding of complex and socially mediated diseases such as obesity [ 25 ]. In spite of an increasing recognition of the integral role of patient experience in health research [ 25 , 26 ], the voices of patients remain largely underrepresented in obesity research [ 27 , 28 ].

Systematic reviews and syntheses of qualitative studies are recognised as a useful contribution to evidence and policy development [ 29 ]. To the best of the authors’ knowledge, this will be the first systematic review and synthesis of qualitative studies focusing on the lived experience of people with obesity. While systematic reviews have been carried out on patient experiences of treatments such as behavioural management [ 30 ] and bariatric surgery [ 31 ], this review and synthesis will be the first to focus on the experience of living with obesity rather than patient experiences of particular treatments or interventions. This focus represents a growing awareness that ‘patients have a specific expertise and knowledge derived from lived experience’ and that understanding lived experience can help ‘make healthcare both effective and more efficient’ [ 32 ].

This paper outlines a protocol for the systematic review of qualitative studies based on the lived experience of people with obesity. The findings of this review will be synthesised in order to develop an overview of the lived experience of patients with obesity. It will look, in particular, at patient concerns around the risks of obesity and their aspirations for response to obesity treatment.

The review protocol has been registered within the PROSPERO database (registration number: CRD42020214560) and is being reported in accordance with the reporting guidance provided in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement [ 33 , 34 ] (see checklist in Additional file  1 ).

Information sources and search strategy

The primary source of literature will be a structured search of the following electronic databases (from January 2011 onwards—to encompass the increase in research focused on patient experience observed over the last 10 years): PubMed, Embase, PsycInfo, PsycArticles and Dimensions. There is no methodological agreement as to how many search terms or databases out to be searched as part of a ‘good’ qualitative synthesis (Toye et al. [ 35 ]). However, the breadth and depth of the search terms, the inclusion of clinical and personal language and the variety within the selected databases, which cover areas such as medicine, nursing, psychology and sociology, will position this qualitative synthesis as comprehensive. Grey literature will not be included in this study as its purpose is to conduct a comprehensive review of peer-reviewed primary research. The study’s patient advisory board will be consulted at each stage of the review process, and content experts and authors who are prolific in the field will be contacted. The literature searches will be designed and conducted by the review team which includes an experienced university librarian (MB) following the methodological guidance of chapter two of the JBI Manual for Evidence Synthesis [ 36 ]. The search will include a broad range of terms and keywords related to obesity and qualitative research. A full draft search strategy for PubMed is provided in Additional file  2 .

Eligibility criteria

Studies based on primary data generated with adults with obesity (operationally defined as BMI >30) and focusing on their lived experience will be eligible for inclusion in this synthesis (Table  1 ). The context can include any country and all three levels of care provision (primary, secondary and tertiary). Only peer-reviewed, English language, articles will be included. Studies adopting a qualitative design, such as phenomenology, grounded theory or ethnography, and employing qualitative methods of data collection and analysis, such as interviews, focus groups, life histories and thematic analysis, will be included. Publications with a specific focus, for example, patient’s experience of bariatric surgery, will be included, as well as studies adopting a more general view of the experience of obesity.

Screening and study selection process

Search results will be imported to Endnote X9, and duplicate entries will be removed. Covidence [ 38 ] will be used to screen references with two reviewers (EF and EH) removing entries that are clearly unrelated to the research question. Titles and abstracts will then be independently screened by two reviewers (EF and EH) according to the inclusion criteria (Table  1 ). Any disagreements will be resolved through a third reviewer (DMcG). This layer of screening will determine which publications will be eligible for independent full-text review by two reviewers (EF and EH) with disagreements again being resolved by a third reviewer (DMcG).

Data extraction

Data will be extracted independently by two researchers (EF and EH) and combined in table format using the following headings: author, year, title, country, research aims, participant characteristics, method of data collection, method of data analysis, author conclusions and qualitative themes. In the case of insufficient or unclear information in a potentially eligible article, the authors will be contacted by email to obtain or confirm data, and a timeframe of 3 weeks to reply will be offered before article exclusion.

Quality appraisal of included studies

This qualitative synthesis will facilitate the development of a conceptual understanding of obesity and will be used to inform the development of policy and practice. As such, it is important that the studies included are themselves of suitable quality. The methodological quality of all included studies will be assessed using the critical appraisal skills programme (CASP) checklist, and studies that are deemed of insufficient quality will be excluded. The CASP checklist for qualitative research comprises ten questions that cover three main issues: Are the results of the study under review valid? What are the results? Will the results help locally? Two reviewers (EF and EH) will independently evaluate each study using the checklist with a third and fourth reviewer (DMcG and MB) available for consultation in the event of disagreement.

Data synthesis

The data generated through the systematic review outlined above will be synthesised using thematic synthesis as described by Thomas and Harden [ 39 ]. Thematic synthesis enables researchers to stay ‘close’ to the data of primary studies, synthesise them in a transparent way and produce new concepts and hypotheses. This inductive approach is useful for drawing inference based on common themes from studies with different designs and perspectives. Thematic synthesis is made up of a three-step process. Step one consists of line by line coding of the findings of primary studies. The second step involves organising these ‘free codes’ into related areas to construct ‘descriptive’ themes. In step three, the descriptive themes that emerged will be iteratively examined and compared to ‘go beyond’ the descriptive themes and the content of the initial studies. This step will generate analytical themes that will provide new insights related to the topic under review.

Data will be coded using NVivo 12. In order to increase the confirmability of the analysis, studies will be reviewed independently by two reviewers (EF and EH) following the three-step process outlined above. This process will be overseen by a third reviewer (DMcG). In order to increase the credibility of the findings, an overview of the results will be brought to a panel of patient representatives for discussion. Direct quotations from participants in the primary studies will be italicised and indented to distinguish them from author interpretations.

Assessment of confidence in the review findings

Confidence in the evidence generated as a result of this qualitative synthesis will be assessed using the Grading of Recommendations Assessment, Development and Evaluation Confidence in Evidence from Reviews of Qualitative Research (GRADE CERQual) [ 40 ] approach. Four components contribute to the assessment of confidence in the evidence: methodological limitations, relevance, coherence and adequacy of data. The methodological limitations of included studies will be examined using the CASP tool. Relevance assesses the degree to which the evidence from the primary studies applies to the synthesis question while coherence assesses how well the findings are supported by the primary studies. Adequacy of data assesses how much data supports a finding and how rich this data is. Confidence in the evidence will be independently assessed by two reviewers (EF and EH), graded as high, moderate or low, and discussed collectively amongst the research team.

Reflexivity

For the purposes of transparency and reflexivity, it will be important to consider the findings of the qualitative synthesis and how these are reached, in the context of researchers’ worldviews and experiences (Larkin et al, 2019). Authors have backgrounds in health science (EF and EH), education (DMcG and EF), nursing (EH), sociology (DMcG), philosophy (EF) and information science (MB). Prior to conducting the qualitative synthesis, the authors will examine and discuss their preconceptions and beliefs surrounding the subject under study and consider the relevance of these preconceptions during each stage of analysis.

Dissemination of findings

Findings from the qualitative synthesis will be disseminated through publications in peer-reviewed journals, a comprehensive and in-depth project report and presentation at peer-reviewed academic conferences (such as EASO) within the field of obesity research. It is also envisaged that the qualitative synthesis will contribute to the shared value analysis to be undertaken with key stakeholders (including patients, clinicians, payers, policy makers, regulators and industry) within the broader study which seeks to create a new narrative around obesity diagnosis and treatment by foregrounding patient experiences and voice(s). This synthesis will be disseminated to the 29 project partners through oral presentations at management board meetings and at the general assembly. It will also be presented as an educational resource for clinicians to contribute to an improved understanding of patient experience of living with obesity.

Obesity is a complex chronic disease which increases the risk of long-term medical complications and a reduced quality of life. It affects a significant proportion of the world’s population and is a major public health concern. Obesity is the result of a complex interplay of multiple factors including genetic, metabolic, behavioural and environmental factors. In spite of this complexity, obesity is often construed in simple terms as a failure of willpower. People with obesity are subject to weight bias, stigma and discrimination which in themselves result in increased risk of mobility or mortality. Research in the area of obesity has tended towards measurable outcomes and quantitative variables that fail to capture the complexity associated with the experience of obesity. A need to rethink how we approach obesity has been identified—one that represents the voices and experiences of people living with obesity. This paper outlines a protocol for the systematic review of available literature on the lived experience of people with obesity and the synthesis of these findings in order to develop an understanding of patient experiences, their concerns regarding the risks associated with obesity and their aspirations for response to obesity treatment. Its main strengths will be the breadth of its search remit—focusing on the experiences of people with obesity rather than their experience of a particular treatment or intervention. It will also involve people living with obesity and its findings disseminated amongst the 29 international partners SOPHIA research consortium, in peer reviewed journals and at academic conferences. Just as the study’s broad remit is its strength, it is also a potential challenge as it is anticipated that searchers will generate many thousands of results owing to the breadth of the search terms. However, to the best of the authors’ knowledge, this will be the first systematic review and synthesis of its kind, and its findings will contribute to shaping the optimisation of future obesity understanding and treatment.

Availability of data and materials

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Abbreviations

Body mass index

Critical appraisal skills programme

Grading of Recommendations Assessment, Development and Evaluation Confidence in Evidence from Reviews of Qualitative Research

Innovative Medicines Initiative

Medical Subject Headings

Population, phenomenon of interest, context, study type

Stratification of Obesity Phenotypes to Optimize Future Obesity Therapy

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Acknowledgements

Any amendments made to this protocol when conducting the study will be outlined in PROSPERO and reported in the final manuscript.

This project has received funding from the Innovative Medicines Initiative 2 Joint Undertaking (JU) under grant agreement No 875534. The JU receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA and T1D Exchange, JDRF and Obesity Action Coalition. The funding body had no role in the design of the study and will not have a role in collection, analysis and interpretation of data or in writing the manuscript.

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EF conceptualised and designed the protocol with input from DMcG and MB. EF drafted the initial manuscript. EF and MB defined the concepts and search items with input from DmcG, CleR and JN. MB and EF designed and executed the search strategy. DMcG, CleR, JN and EH provided critical insights and reviewed and revised the protocol. All authors have approved and contributed to the final written manuscript.

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Additional file 1:..

PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) 2015 checklist: recommended items to address in a systematic review protocol*.

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Farrell, E., Bustillo, M., le Roux, C.W. et al. The lived experience of people with obesity: study protocol for a systematic review and synthesis of qualitative studies. Syst Rev 10 , 181 (2021). https://doi.org/10.1186/s13643-021-01706-5

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• Published: 27 January 2020

Epidemiology and Population Health

Evidence from big data in obesity research: international case studies

• Emma Wilkins 1 ,
• Ariadni Aravani 1 ,
• Amy Downing 1 ,
• Adam Drewnowski 2 ,
• Claire Griffiths 3 ,
• Stephen Zwolinsky 3 ,
• Mark Birkin 4 ,
• Seraphim Alvanides 5 , 6 &
• Michelle A. Morris   ORCID: orcid.org/0000-0002-9325-619X 1  

International Journal of Obesity volume  44 ,  pages 1028–1040 ( 2020 ) Cite this article

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Background/objective

Obesity is thought to be the product of over 100 different factors, interacting as a complex system over multiple levels. Understanding the drivers of obesity requires considerable data, which are challenging, costly and time-consuming to collect through traditional means. Use of ‘big data’ presents a potential solution to this challenge. Big data is defined by Delphi consensus as: always digital , has a large sample size, and a large volume or variety or velocity of variables that require additional computing power (Vogel et al. Int J Obes. 2019). ‘Additional computing power’ introduces the concept of big data analytics. The aim of this paper is to showcase international research case studies presented during a seminar series held by the Economic and Social Research Council (ESRC) Strategic Network for Obesity in the UK. These are intended to provide an in-depth view of how big data can be used in obesity research, and the specific benefits, limitations and challenges encountered.

Methods and results

Three case studies are presented. The first investigated the influence of the built environment on physical activity. It used spatial data on green spaces and exercise facilities alongside individual-level data on physical activity and swipe card entry to leisure centres, collected as part of a local authority exercise class initiative. The second used a variety of linked electronic health datasets to investigate associations between obesity surgery and the risk of developing cancer. The third used data on tax parcel values alongside data from the Seattle Obesity Study to investigate sociodemographic determinants of obesity in Seattle.

Conclusions

The case studies demonstrated how big data could be used to augment traditional data to capture a broader range of variables in the obesity system. They also showed that big data can present improvements over traditional data in relation to size, coverage, temporality, and objectivity of measures. However, the case studies also encountered challenges or limitations; particularly in relation to hidden/unforeseen biases and lack of contextual information. Overall, despite challenges, big data presents a relatively untapped resource that shows promise in helping to understand drivers of obesity.

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Acknowledgements

The ESRC Strategic Network for Obesity was funded via ESRC grant number ES/N00941X/1. The authors would like to thank all of the network investigators ( https://www.cdrc.ac.uk/research/obesity/investigators/ ) and members ( https://www.cdrc.ac.uk/research/obesity/network-members/ ) for their participation in network meetings and discussion which contributed to the development of this paper.

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Emma Wilkins, Ariadni Aravani, Amy Downing & Michelle A. Morris

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Wilkins, E., Aravani, A., Downing, A. et al. Evidence from big data in obesity research: international case studies. Int J Obes 44 , 1028–1040 (2020). https://doi.org/10.1038/s41366-020-0532-8

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CASE REPORT article

Clinical challenge: patient with severe obesity bmi 46 kg/m 2.

• Section of Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States

Obesity causes and exacerbates many disease processes and affects every organ system. Thus it is not surprising that clinical providers are often overwhelmed with the multitude of symptomatology upon initial presentation in patients with obesity. However, despite a “complicated medical history,” a systematic, organized approach in obesity medicine utilizes a personalized-tailored treatment strategy coupled with understanding of the disease state, presence of comorbidities, contraindications, side effects, and patient preferences. Here, we present the case of a young patient with Class 3b severe obesity, several obesity-related complications, and extensive psychological history. Through synergistic and additive treatments (behavioral/nutritional therapy combined with anti-obesity pharmacotherapy and concurrent enrollment in our bariatric surgery program), the patient was able to achieve significant −30.5% total body weight loss with improvement of metabolic parameters. Though these results are not typical of all patients, we must emphasize the need to encompass all available anti-obesity therapies (lifestyle, pharmacotherapy, medical devices, bariatric surgery in monotherapy or combination) in cases of refractory or severe obesity, as we do similarly for other disease modalities such as refractory hypertension or poorly controlled Type 2 diabetes that requires robust escalation in therapy.

Clinical Challenge

A 31 year old patient with a past medical history of Class 3 obesity BMI 46 kg/m 2 , Type 2 diabetes mellitus (A1c <5.7%, well controlled on metformin), polycystic ovarian syndrome, non-alcoholic steatosis of the liver, pulmonary and neurosarcoidosis on infliximab and methotrexate, and chronic worsening pain presents for weight management evaluation. She had a history of opioid use disorder due to the chronic pain, though in remission. She had been on several weight-promoting pain medications for symptom control, including gabapentin, duloxetine and nortriptyline. Contributing factors over the years to her weight gain also included her diagnosis of Bipolar Disorder with antipsychotic medication-induced weight gain (previously trialed aripiprazole, responded to lurasidone with decreasing efficiency, and now finally stable on paliperidone though weight gain promoting). Her highest adult weight was her current weight of 295 pounds with a lowest adult weight of 140 lbs. that pre-dated her Bipolar and sarcoidosis diagnoses several years ago. She had stable eating patterns, and often chose healthy meals such as hummus, vegetables, Greek salads, and lean meats, though had a weakness for sweet cravings. She engaged in structured gym exercise for 30 minutes three times per week despite the chronic pain. Recent stressors included her close aunt who had been diagnosed with cancer. She also suffered from insomnia and had been evaluated closely with sleep therapists and sleep hygiene specialists. Her polysomnogram was negative for sleep apnea.

What Would You Do Next?

A. Offer more aggressive intensive lifestyle therapy intervention

B. Trial of anti-obesity medication if option A above becomes ineffective

C. Metabolic and bariatric surgery only as anti-obesity medication would be contraindicated given her history of opioid use

D. Trial of anti-obesity medication for 3 months with concurrent referral to bariatric surgery

The patient depicted in the case has chronic, debilitating severe obesity classification with several inflammatory obesity-related comorbidities and other contributing etiology to her weight gain.

In regards to lifestyle intervention, the patient was started on a healthy low fat high fiber diet with increased consumption of vegetables, while minimizing intake of processed foods, added sugar, trans fats, and refined flours ( 1 ). Nutrient-dense whole foods prepared at home were encouraged. Acceptable macronutrient distribution range is 45–65% carbohydrates, 20–35% total fat of which <10% should be polyunsaturated fats, and 10–35% protein and amino acids 1 . However, obesity-related comorbidities such as type 2 diabetes mellitus, polycystic ovarian syndrome, and non-alcoholic steatosis of the liver suggesting features of insulin resistance need to be taken into consideration when implementing dietary modifications specific to this case. The patient's daily carbohydrate intake should be reduced to 40–50% to combat insulin resistance. Several studies have shown improvement in metabolic parameters and more rapid weight loss when a low carbohydrate diet was implemented initially in the first 3–6 months ( 2 , 3 ). At presentation, the patient's calculated daily protein intake was <20% of total daily intake and increasing her protein intake to 30% reduced her sweet cravings and increased satiety. In addition, she would benefit from at least 150 min per week of structured moderately intensive exercise as tolerated as recommended by The American College of Sports Medicine ( 4 ). Of note, the patient is also under significant stressors. Stress has been very strongly linked to hyperphagia, binging, and obesity ( 5 , 6 ). Stress management would also provide long-term strategies for emotional/stress eating should they arise. Her sleep has been adequately addressed by a specialist multidisciplinary team. Further, the patient was already under intense behavioral therapy given her underlying psychiatric illness. Early behavioral therapy intervention should be strongly considered in patients with adverse psychological factors, eating disorders and underlying psychiatric conditions that would otherwise impede their overall progress toward health goals. However, it may be difficult to promote more aggressive lifestyle intervention alone, especially in a patient with an advanced obesity disease staging who is already making strides to eat healthy and undergoing behavioral therapy.

Furthermore, the patient also meets criteria for initiation of anti-obesity pharmacotherapy (AOM): BMI >27 kg/m 2 plus the presence of one obesity-related comorbidity and/or BMI >30 kg/m 2 in conjunction with lifestyle intervention ( 7 , 8 ). Though the patient has a history of opioid use disorder, it is in remission and there is no active contraindication to AOM. The patient also does not have underlying heart disease, end-stage-renal disease, or acute angle glaucoma that would negate use of several AOM such as phentermine/topiramate, lorcaserin, and naltrexone/bupropion. Liraglutide 3.0 mg would be a first option given its double benefits in patients with severe obesity and diabetes ( 7 ) and other obesity-related comorbidities such as fatty liver ( 9 ) and polycystic ovarian disease ( 10 ). The medication is also generally well-tolerated and safe. Because anti-obesity medications can exert central effects in a patient with Bipolar Disorder, close monitoring and communication with the patient's psychiatrist would be critical. Because her BMI is already very elevated, clinically, both lifestyle changes and pharmacological treatment would be implemented together, rather than separately. Moreover, based on her current body mass index alone of 40 kg/m 2 , the patient meets National Institutes of Health consensus criteria for metabolic and bariatric surgery ( 11 ): BMI 35 kg/m 2 in the presence of at least one obesity-related comorbidity or BMI 40 kg/m 2 . Therefore, it would be prudent to discuss bariatric surgery in this patient given her disease severity.

The correct answer is D. The patient was actually started on AOM with concurrent referral to the institution's bariatric surgery program. Since the patient's insurance did not provide coverage for liraglutide 3.0 mg, she was alternatively prescribed a combination anti-obesity medication therapy (phentermine/topiramate) after discussion with her psychiatrist and other specialists. AOM were instrumental in improving the patient's overall hunger drive, cravings, and satiety. Despite being the best option for her at presentation, the patient was unwilling to undergo the bariatric procedure. Oftentimes, this may be the case in many patients until they consent to surgical intervention or have weight regain on non-surgical therapy. Future guidelines may need to be more definitive about earlier referral to bariatric surgery.

The patient continued AOM long-term, having lost 90 pounds over a 2 year time period ( Figure 1 ). Her BMI now is 28.7 kg/m 2 , weight 205 lbs. (reversed from Class 3 obesity, BMI 46 kg/m 2 , weight 295 lbs.) with improvement in quality of life and obesity-related comorbidities. Liver transaminases that were previously elevated in the context of fatty liver disease normalized along with return of regular menstrual cycles. In the process of losing weight with related attenuation in disease comorbidity and metabolic profile improvement, the patient's neurosarcoidosis continued to show remarkable recovery with stabilization of her mental health conditions and disability. Her specialists reported that this was the best she had been in many years. The patient lost −30.5% of her total body weight, which is typical weight loss achieved by metabolic and bariatric surgery means, through non-surgical intervention.

Figure 1 . Patient's weight graph derived from the electronic health record. The patient lost a total of 90 lbs. over a 2 year time period with adjunctive anti-obesity pharmacotherapy (phentermine/topiramate) in combination with behavioral and lifestyle intervention.

Though these results may not be usual for all patients, it is important to note that all treatment modalities (behavioral, lifestyle, pharmacological, and/or surgical whether as monotherapy or in combination) must be utilized for patients suffering with severe obesity and its devastating consequences on overall health and quality of life. Many of these patients present with complicated disease states and multiple comorbidities. Thus, important health targets include not only weight loss but treatment-enhanced double benefits leading to improvement of comorbidities.

Data Availability Statement

All datasets for this study were directly generated from the patient's electronic health record and are available upon request.

Informed Consent

Written informed consent to publish this case report was obtained from the patient.

Author Contributions

GS and CA contributed and edited the contents of this manuscript.

No external funding was provided for the creation of this manuscript.

Conflict of Interest

GS served as a consultant for Johnson and Johnson and advisor for Rhythm Pharmaceuticals. CA reports grants from Aspire Bariatrics, Myos, the Vela Foundation, the Dr. Robert C. and Veronica Atkins Foundation, Coherence Lab, Energesis, NIH, and PCORI, grants and personal fees from Orexigen, GI Dynamics, Takeda, personal fees from Nutrisystem, Zafgen, Sanofi-Aventis, NovoNordisk, Scientific Intake, Xeno Biosciences, Rhythm Pharmaceuticals, Eisai, EnteroMedics, Bariatrix Nutrition, and other from Science-Smart LLC, outside the submitted work.

Acknowledgments

We would like to thank the patient for permission to publish.

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Keywords: anti-obesity medications, weight loss drugs, combination therapy, bariatric surgery, lifestyle intervention

Citation: Srivastava G and Apovian CM (2019) Clinical Challenge: Patient With Severe Obesity BMI 46 kg/m 2 . Front. Endocrinol. 10:635. doi: 10.3389/fendo.2019.00635

Received: 30 April 2019; Accepted: 03 September 2019; Published: 02 October 2019.

Reviewed by:

Copyright © 2019 Srivastava and Apovian. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Gitanjali Srivastava, geet5sri@gmail.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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The Childhood Obesity Data Initiative: A Case Study in Implementing Clinical-Community Infrastructure Enhancements to Support Health Services Research and Public Health

Affiliation.

• 1 Obesity Prevention and Control Branch, Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion (Drs King and Goodman and Mss Harrison and Sucosky), and Center for Surveillance Epidemiology and Laboratory Services (Ms Garret), Centers for Disease Control and Prevention, Atlanta, Georgia; Health Technical Center, The MITRE Corporation, McLean, Virginia (Drs Heisey-Grove and Mork and Messrs Gregorowicz, Chudnov, and Jellison); Denver Public Health, Denver, Colorado (Dr Scott); Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado (Dr Daley); University of Colorado Department of Pediatrics and Children's Hospital Colorado, Aurora, Colorado (Dr Haemer); Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts (Dr Block); Louisiana Public Health Institute, New Orleans, Louisiana (Dr Carton); McKing Consulting Corporation, Atlanta, Georgia (Dr Porter); Public Health Informatics Institute, Decatur, Georgia (Dr Kraus); and Duke University School of Medicine, Durham, North Carolina (Dr Armstrong).
• PMID: 34446638
• PMCID: PMC8781217
• DOI: 10.1097/PHH.0000000000001419

Context: We describe a participatory framework that enhanced and implemented innovative changes to an existing distributed health data network (DHDN) infrastructure to support linkage across sectors and systems. Our processes and lessons learned provide a potential framework for other multidisciplinary infrastructure development projects that engage in a participatory decision-making process.

Program: The Childhood Obesity Data Initiative (CODI) provides a potential framework for local and national stakeholders with public health, clinical, health services research, community intervention, and information technology expertise to collaboratively develop a DHDN infrastructure that enhances data capacity for patient-centered outcomes research and public health surveillance. CODI utilizes a participatory approach to guide decision making among clinical and community partners.

Implementation: CODI's multidisciplinary group of public health and clinical scientists and information technology experts collectively defined key components of CODI's infrastructure and selected and enhanced existing tools and data models. We conducted a pilot implementation with 3 health care systems and 2 community partners in the greater Denver Metro Area during 2018-2020.

Evaluation: We developed an evaluation plan based primarily on the Good Evaluation Practice in Health Informatics guideline. An independent third party implemented the evaluation plan for the CODI development phase by conducting interviews to identify lessons learned from the participatory decision-making processes.

Discussion: We demonstrate the feasibility of rapid innovation based upon an iterative and collaborative process and existing infrastructure. Collaborative engagement of stakeholders early and iteratively was critical to ensure a common understanding of the research and project objectives, current state of technological capacity, intended use, and the desired future state of CODI architecture. Integration of community partners' data with clinical data may require the use of a trusted third party's infrastructure. Lessons learned from our process may help others develop or improve similar DHDNs.

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The authors have indicated no potential conflicts of interest to disclose.

The CODI Collaborative a Abbreviation:…

The CODI Collaborative a Abbreviation: CODI, Childhood Obesity Data Initiative. a The CODI…

Overview of CODI Data Models

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The CODI Query Process Steps a Abbreviations: CODI, Childhood Obesity Data Initiative; DCC,…

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Jason, 15-year-old white male

Jason was a 15-year-old white male who lived with his mother and niece. He expressed a desire to be a healthier weight, but was having difficulty with managing his weight and had not been successful in a general weight management program. His body mass index (BMI) was at the 98th percentile for his age and gender. Jason’s specific concerns included low motivation to change eating and activity behaviors, difficulty resisting cravings for less healthy foods, and lack of social support around weight loss from his family and friends.

Given these concerns, Jason’s psychologist focused on two areas during his brief treatment. The first was on improving Jason’s eating behaviors by addressing his low motivation, reducing cravings and binge eating, and improving family communication around eating. The second area of focus was on improving his physical activity by increasing opportunities for activities with friends and family. Jason was the primary participant in treatment because of his desire to take greater ownership of his own health and behaviors. This was considered appropriate by the psychologist given his age and developmental stage.

The initial target of therapy was improving Jason’s motivation to make changes. He believed that making changes would be difficult, stressful, and not necessarily effective. However, Jason also said that he wanted to make changes to his weight and health in order to increase his self-esteem and feel more comfortable around his friends who did not struggle with their weight. Jason’s psychologist used motivational interviewing techniques to draw attention to the discrepancy between Jason’s stated goals and his ambivalence around related behavior change. Addressing these concerns at the start enabled Jason to make progress on his other treatment goals as his motivation increased.

Social support around making behavior change was difficult, given that Jason’s friends did not experience difficulties with their weight, and their social activities often centered on food. To address these concerns, Jason learned how to plan ahead of social activities, specifically by identifying healthier options and appropriate portion sizes at the restaurants his friends typically frequented. Jason also developed strategies for feeling included while making choices more in line with his health goals. In addition, he determined that his friends enjoyed some activities that involved physical activity (walking on a trail at a nearby park, for example) that he could suggest without referencing his health or weight loss goals. Further, Jason’s psychologist used cognitive behavioral strategies to target Jason’s negative self-image, which developed in response to his friends’ focus on appearance and their seeming lack of difficulty with weight.

Jason’s relationship with his mother was also a barrier to making changes to his health behaviors. His mother was included in a few of the sessions in order to address their communication difficulties and increase Jason’s support from his family. During these sessions, Jason and his mother discussed common triggers of arguments about food. For example, Jason’s mother reported that she “couldn’t help” but make comments to Jason about making good choices when going out with friends. Jason noted that he often responded by eating “to spite” his mother. The psychologist helped Jason and his mother develop and practice new communication strategies related to food and exercise topics. These strategies included Jason giving his mother concrete suggestions about how she could provide needed support, such as buying healthful foods at the market and helping plan family activities that included physical activity.

Recognizing that inappropriate dieting has been linked to the development of eating disorders, the psychologist wanted to address binge and emotional eating and establish healthier coping patterns. The psychologist provided psychoeducation about food cravings and binge eating. The psychologist also used mindfulness strategies, such as increasing Jason’s attention to his physical sensations, to illustrate key differences between craving and hunger. The psychologist conducted two in vivo food exposure sessions in which Jason brought a frequently-craved snack and then was guided through a mindfulness activity.

As their sessions progressed, Jason reported paying more attention to his internal hunger, craving, and fullness cues. He became aware of high-risk time periods for losing control over eating, such as being hungry and stressed. Jason began to track his moods and eating behaviors, specifically around binge eating, in order to identify binge triggers and use his new cognitive behavioral skills to manage his emotions without the use of food. Pre-planned healthful meals and small snacks also helped prevent him from becoming overly hungry.

Jason was able to improve his motivation, achieve behavioral goals through increased social support and communication, and address problematic areas of cravings and binge eating. Working with the psychologist, his BMI began to decline. He then focused his efforts on interventions managed by other members of the multidisciplinary team.

Other Case Examples

• Younger girl Carmen, 6-year-old Latina girl
• Middle-school boy Marcus, 11-year-old African-American boy
• Teenage female June, 18-year-old biracial female

Physical Activity: Case Studies

Resources Policy Dossiers Physical Activity Physical Activity: Case Studies

• Sugar-Sweetened Beverage Tax
• Digital Marketing
• School-based interventions
• Community-level interventions
• Pregnancy & Obesity
• Childhood Obesity Treatment
• Front-of-pack nutrition labelling
• Obesity & COVID-19
• Physical Activity
• Food Systems
• Weight Stigma

The case studies below exemplify some of the interventions and policies implemented around the globe.

Acknowledging the importance of external factors including the social, cultural and economic environment, read the case studies below to learn more about existing interventions designed to foster environments that promote active living, and identify some of the barriers and enablers to implement physical activity-oriented interventions.

Association of sports and physical activity with obesity among teenagers in Poland

This study aimed “to assess the relationship between the body mass index and sports and physi­cal activities in an unbiased, simple, random sample of teenagers from mid-north-eastern Poland.” 

Obesity, eating behaviour and physical activity during COVID-19 lockdown: A study of UK adults.

This study of UK adults between April-May 2020 examined physical activity levels, diet quality amongst other factors during the COVID-19 lockdown. The common barriers to weight management because of the pandemic were explored. 

Impact of physical activity on the association of overweight and obesity with cardiovascular disease: The Rotterdam Study

The Rotterdam Study examined the “association between overweight and obesity and cardiovascular disease risk as a function of physical activity levels in a middle-aged and elderly population.”

Improving the Metabolic and Mental Health of Children with Obesity: A School-Based Nutrition Education and Physical Activity Intervention in Wuhan, China

This research evaluated “the effectiveness of a school-based nutrition education and physical activity intervention on cardiovascular risk profile and mental health outcomes among Chinese children with obesity.” 

Intervention fidelity in a school-based diet and physical activity intervention in the UK: Active for Life Year 5

This study investigates the effectiveness and degree to which the Active for Life Year 5 (AFLY5) programme was delivered as intended in UK schools. The educational programme is targeted at 9–to-10-year-old children to increase their physical activity level, decrease sedentary behaviour, and promote the consumption of healthy food products.

‘Let’s Move It’ – a school-based multilevel intervention to increase physical activity and reduce sedentary behaviour among older adolescents in vocational secondary schools: a study protocol for a cluster-randomised trial

Let’s Move It trial evaluated “the effectiveness and the cost-effectiveness of a school-based, multi-level intervention, on physical activity and sedentary behaviours, among vocational school students.” 

Built Environment, Physical Activity, and Obesity: Findings from the International Physical Activity and Environment Network (IPEN) Adult Study

The International Physical Activity and Environment Network Adult study “shares data on the link between the built environment and physical activity and BMI across 12 countries on 5 continents (n > 14,000).” The study aimed to measure the associations of built environments with physical activity and overweight and obesity.

Influences of Physical and Social Neighbourhood Environments on Children's Physical Activity and Obesity

The study examined the role that the environments we live in have on physical activity levels and vice versa amongst 650 children. The study concluded the policy action to address childhood and adolescent obesity should consider both social and physical environments. 

Effect of a Workplace Weight-Loss Program for Overweight and Obese Healthcare Workers

The aim of the study was to assess the impact of a workplace weight-loss programme on weight loss, physical, behavioural, and mental well-being among people living with overweight or obesity.

Bidirectional association between stress and physical activity in adults with overweight and obesity.

The current study investigated the bidirectional association between stress and physical activity in adults with overweight and obesity. 

Physical Activity Dossier

This page will be constantly updated with new studies as they come about. In the meantime, you can view our other elements of the physical activity dossier.

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• v.317(7153); 1998 Jul 25

Evidence based case report

Helping an obese patient make informed choices.

Not long ago, a patient, whom I will call Mrs Bariatrico, asked me to prescribe a diet pill for her. Mrs Bariatrico is a middle class woman aged 48 years. She is 1.6 m tall and weighs 77.2 kg. Her body mass index is 30.2 and her waist to hip ratio is 1.0. Mrs Bariatrico is healthy and does not smoke. She told me she plans to enrol in a commercial diet programme and believes her ability to change her lifestyle is good. 1 Her main concern is cosmetic—she values “looking good” and considers weight loss an important outcome.

As her primary care provider, I had several concerns. I knew the health insurance system that serves Mrs Bariatrico has no formal weight loss programmes, and the cost of appetite suppressing drugs is not reimbursed. I had some doubts about my own ability to manage obesity and asked the following questions:

• What are the actual health risks associated with obesity in a middle aged woman with few cardiovascular risk factors?
• What are the expected benefits and hazards of weight loss?
• What are Mrs Bariatrico’s treatment options and their expected benefits and adverse effects?

Risks of obesity

Obesity is a chronic condition associated with hyperlipidaemia, hypertension, non-insulin dependent diabetes, gall bladder disease, some cancers, sleep apnoea, and degenerative joint disease. 2 , 3 Assessing the magnitude of risk for these conditions is complicated by several elements: many patients have several interacting risks; measuring the impact of some risks requires large, long cohort studies; and there are several confounding factors such as smoking and the duration of obesity. Regardless of these cautions, studies suggest that people who are more than 20% overweight have prevalences of hyperlipidaemia, hypertension, and diabetes that are between 1.5 and 3.5 times higher than those in people whose weight is normal. 2 , 3 The morbidity risks increase steadily from a body mass index of 25-30 and more rapidly at higher index values. Mortality risks increase above body mass indices of 20-27. 4 , 5 Relevant to Mrs Bariatrico, values of 29.0-31.9 in non-smoking middle aged women are associated with a relative mortality risk of 1.7 (95% confidence interval. 1.4 to 2.2; reference body mass index <19). 4

Expected benefits and hazards

Randomised trials confirm several physiological benefits—including reductions in blood pressure and glucose and lipid concentrations—when weight is reduced by 10-15%. 2 Trials are neither large enough nor long enough to identify survival benefits. One observational study that lasted 12 years showed that an intentional weight loss of 0.5-9.0 kg in overweight women with disorders related to obesity was associated with a 20% reduction in all cause mortality (relative risk=0.80; 0.68 to 0.94). 6 Potential hazards of weight loss include increased risks of gall stones during rapid weight loss and loss of bone density. 2

Treatment options

A comprehensive systematic review from the Centre for Reviews and Dissemination evaluates treatment options appropriate for Mrs Bariatrico. 7 These include diet, exercise, and appetite suppressing drugs. A recent book describes many complementary therapies, including herbal remedies and chromium, but none have been adequately evaluated in controlled trials. 8

Diet and exercise

Randomised controlled trials show that diets allowing an intake of 1200 kcal/day coupled with behaviour modification result in an approximate weight loss of 8.5 kg at 20 weeks. 9 Providing patients with food and meal plans, focusing on restricting fat as well as calories, and encouraging daily self monitoring of weight may be particularly effective strategies. 7 Very low calorie diets of less than 800 kcal/day result in a weight loss of approximately 20 kg at 12 to 16 weeks. One half to two thirds of the weight loss is maintained at one year. 9 Adding regular aerobic exercise results in minimal additional weight loss (approximately 2.5 kg after six months) and limits the amount of weight regained. 10 Resistance exercise has little effect on weight but increases the lean body mass. 10

Appetite suppressants

Double blind randomised trials of longer than six months’ duration show that antidepressant serotonergic agents such as fluoxetine are not effective weight loss treatments. 7 , 11 Other serotonergic agents, dexfenfluramine and fenfluramine (a racemic mixture of d -fenfluramine and l -fenfluramine), are effective when combined with diet. 7 , 11 Five trials, in which 1029 patients participated, showed that the weight loss with dexfenfluramine was 2.5 to 8.7 kg greater than with placebo at six months; two trials showed losses of 2.6 and 4.2 kg at 12 months. 11 The combination of fenfluramine and phentermine (colloquially known as fen-phen) resulted in a loss of 9.7 kg after six months compared with placebo. Two new drug are sibutramine (serotonin and noradrenergic reuptake inhibitor) and orlistat (a fat absorption inhibitor). In one multicentre randomised trial, sibutramine showed a 2.8 kg loss compared with placebo at 12 months. 7 In a preliminary report from one centre of a multicentre trial comparing orlistat with placebo, weight reduction with orlistat was 3.1 kg more than with placebo at six months. 12 Trial data beyond 12 months of active treatment are not available for either of the two agents, and effects on mortality are not known.

Adverse effects that occur in more than 10% of patients taking dexfenfluramine include tiredness, diarrhoea, and dry mouth. Use of appetite suppressants (mostly dexfenfluramine) for more than three months is associated with pulmonary hypertension. 13 The risk is estimated at 23-46 cases per million per year or one in 22 000-44 000 patients taking appetite suppressing drugs. Highly publicised case series describe unusual heart valve deterioration in 60 otherwise healthy women taking newer agents. 14 , 15 Most were taking the combination of fenfluramine and phentermine, but six were taking either fenfluramine or dexfenfluramine alone. 14 , 15 In addition, a case series of 291 asymptomatic people taking these drugs showed that 92 had evidence of valvular disease, primarily aortic regurgitation. 16 This information prompted manufacturers to withdraw dexfenfluramine and fenfluramine from the market in September 1997.

The informed decision

I gave Mrs Bariatrico feedback on the health risks of obesity, listed the treatment options, and advised her about the expected effects. She viewed the health risks of obesity as relatively minor and reiterated her primary value of losing weight so she would “look and feel good.” She was surprised that the weight loss expected from diet pills was not greater and worried about possible serious adverse heart effects. She was determined to try a low fat, low calorie diet and daily exercise. I praised her willingness to tackle difficult lifestyle changes. On her way out the door, she turned, smiled at me, and requested a prescription for phentermine—one of the few remaining appetite suppressants available on the market.

Wanting to “look and feel good” is often the spur to undertaking difficult lifestyle changes

Funding: None.

Conflict of interest: None.

• Funding Opportunities

 Measures Registry User Guides

Case Studies

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Stay up to date

The Measures Registry User Guides include several examples or case studies for each of the four domains. These case studies are listed in the table below. For ease of use, we have grouped the project designs for the case studies into three categories—intervention, epidemiology, and surveillance. However, these types of projects can be characterized in other ways, as well, as detailed in the framework for individual physical activity .

The user guide authors described various approaches in their case studies. For consistency across the four domains, we applied three major steps to these approaches—background, considerations, and measure selection.

Readers will note that the case studies differ in one important aspect. The food environment and physical activity environment user guides mention specific measures that were considered and then selected to meet the needs of the specific projects described in the case studies. In contrast, the case studies for the individual diet and individual physical activity domains describe measures in a more generic way.

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A case study: obesity and the metabolic syndrome. a three-pronged program, targeting education, close follow-up and a dietary supplement, significantly decrease body weight and body fat, grethe s birketvedt.

Medical Center for Obesity and Research, Baerum, Oslo, Norway

E-mail : [email protected]

Carl Fredrik Schou

Teres Colosseum, Oslo, Norway

Erling Thom

ETC Research and Development, Oslo, Norway

DOI: 10.15761/IOD.1000143

A 38-year old woman with a body fat content of 52.2% and a BMI of 48.2 kg/m 2 was seeking medical treatment in an outpatient obesity clinic in Oslo, Norway. She suffered from a severe abdominal hernia and was not qualified for surgery of this condition until her BMI was under 30 kg/m 2 .  Additionally, she was severely challenged in terms of mobility as she was born with cerebral palsy and required either a wheel chair or crutches to get around. Over the years she had sought several treatment options to control her obesity but with no success. She did not qualify for bariatric surgery and was severely depressed when she came to the clinic. After examination and diagnosis, the decision was made to begin a multi-pronged treatment using a natural dietary supplement, combined with the customized educational program called “The Body in the Brain”, and a close medical follow-up with regular appointments to the outpatient clinic.  After twenty-three months of treatment, the woman had lost 38 kg of bodyweight and had normalized fat percentage for her age and gender. In conclusion, it is possible to successfully treat severe obesity and return a patient to a normal body fat percentage with the combination of a natural dietary supplement, a designed diet composition and a weight loss behavioral program.

obesity, weight loss, metabolic syndrome

Introduction

Obesity and the metabolic syndrome are linked together [1]. When an individual gets severely obese, insulin resistance, hypertension and increased abdominal circumference follow as a natural cause due to the excess fat in the body. Obesity and the metabolic syndrome has been extensively researched and today clinical evidence implicates intra-abdominal adiposity as a powerful driving force for elevated cardio metabolic risk [2]. This association appears to arise directly, via secretion of adipokines, and indirectly, through promotion of insulin resistance.

The most important therapeutic intervention effective in subjects with the metabolic syndrome should focus on weight reduction and regular daily physical activities. Health experts agree that making lifestyle changes, including following a healthy eating pattern, reducing caloric intake, and engaging in physical activity, are the basis for achieving long-term weight loss [3,4]. However, weight-loss and weight-management regimens have frequently been ineffective. Therefore, effective medical interventions to manage weight gain and slow or prevent progression to obesity are needed. Control of diet and exercise are cornerstones of the management of excess weight. A number of nutritional approaches and diets with different proportions of lipids, proteins and carbohydrates have been prescribed for weight loss. Initial guidance on weight loss was earlier years a restriction in saturated fats that unfortunately did not necessarily result in weight loss. Recently, a shift towards a reduction in refined carbohydrates has been a new approach to lose weight.  

Several studies have indicated that fiber-rich foods and fiber supplements have moderate weight reducing effects, and may also improve the lipid profile in overweight and obese individuals [5,6]. There are hundreds of weight loss products sold over the counter today. Typically, these OTC supplements have not been clinically tested, can have significant unwanted side effects and not yield successful results in helping people to lose weight.

The natural product, used in this case study is supplement that consists of a unique combination of three natural ingredients: white kidney bean extract, locust bean gum extract and green tea extract that affect weight loss with little to no side effects.  The white kidney bean extract is phaseolus vulgaris, a bean extract containing phaseolamin. Phaseolamin is a glycoprotein found mainly in white and red kidney beans and is an effective alfa-amylase inhibitor [7]. The extract of locust bean gum, is a seed-coat extract that decreases ghrelin [8], the hunger hormone and make you feel faster satiated and will postpone the hunger sensation after a meal. Locust bean gum has also shown lipid lowering effects in several studies [9]. The third ingredient is a green tea extract [10-12], Camellia sinensis with anti-inflammatory and antioxidant properties with a small increase in the energy expenditure.

Aim of study

The aim of this study was to investigate whether a dietary supplement with white kidney bean extract, locust bean gum extract and green tea extract in combination with a program with lifestyle changes would enhance weight loss and fat loss and improve the metabolic parameters in a severe obese patient with the metabolic syndrome.

A 38 year old woman with a history of obesity, diabetes type 2 and hypertension was seeking treatment in an out-patient clinic in Oslo, Norway for medical weight loss management. She was well aware of the link between obesity, diabetes and cardiovascular disease and felt this appointment she had asked for was her last chance in getting help with her health problems.

She had been normal weight as a child and adolescent, but do to a dependency of crutches and a wheelchair she had gradually put on weight in her twenties. She was married with two young children and she increased in weight after each child birth. She suffered a severe abdominal hernia that stressed her, but she had been refused surgery due to her heavy weight.

She had in her childhood and teens always been of normal weight, active and healthy in spite of her physical disabilities. When she got married, she gradually gained weight and the weight culminated after her second child was born. She had developed diabetes type 2 and hypertension after her children were born, and was medicated with antihypertensive and antidiabetics. Her primary care physician had not really been interested in her weight and had several times suggested higher doses of medications or insulin injections. The patient was not interested in insulin injections as she was afraid of gaining more weight.

Our patient had been sedentary the last 5 years due to the abdominal hernia. She had tried many weight loss efforts on her own, had started working with a personal trainer and had weekly sessions with a physical therapist. Her diet had been high in fat and calories although she was very well educated in nutritious food. However, she admitted to overeating, and periods of binging. She drunk about 2.5 liter of diet soda a day including diet juice. She was very conscious about eating habits when it came to her two kids, and they were both healthy and in normal weight. She had a university education and was well informed of her health situation. But she was under much stress in her daily life and struggled daily to get help from health authorities.

Her initial anthropometric measurements included a weight of 125kg with a height of 1.61m, a body mass index (BMI) of 48.2kg/m 2 which classified her as morbidly obese. Her fat % was 52.2% with 65 kg fat mass measured by bioelectrical impedance analysis (BIA)[13] (Tanita Body Composition Analyzer BC-418) for analyzing the composition of the body, such as weight, lean body mass (LBM), total body water(TBW), fat free mass (FFM) and basal metabolic rate (BMR). Her HbA1c had the last 2 months ranged from 11.7% till 8.8% and her hypertension was 160/95 mm Hg.

Informed consent

The patient has signed and approved the consent form.

On the first visit to our clinic, the patient was advised of which food items of simple carbohydrates she should try to avoid in her daily diet. She was given restrictions in caloric content and a diet plan, specifically designed for her health situation with emphasis on her hypertension and diabetes type 2. She was also advised to drink water with a slice of lime instead of diet sodas and diet juice. One of her main goals was to be able to not require medications for control of her hypertension that would then improve her diabetes type 2 and simultaneously decrease her weight. It was extremely important for the treating physician to give her food compositions that targeted the ability to relieve stress in the gut-brain axis.

Her resting metabolic rate (RMR) was measured to 1828 kcal and the physician designed a diet in the range of 1200kcal to 1600 kcal. In that way, she at least could have a deficit of about 400 kcal a day taking into account her limited physical activity level.  In a two week period this regimen would theoretically allow her approximately a 0.5 kg loss in weight. Due to her decrease in simple carbohydrates she was advised to check her blood sugar 3 times per day and write the recordings down until next meeting. She was instructed on how to decrease her diabetes medication based on her blood sugar levels.

The weight management program at our clinic was continuing with bi-weekly visits by the patient for the next six weeks, and then monthly visits after that time. Furthermore, the patient  was advised after six weeks to additionally take one capsule of the dietary supplement twenty minutes before each of the main meals, breakfast, lunch and dinner. 

On a monthly basis, her weight and body fat percentage were recorded with BIA at the doctor visits. Moreover, she was given 1 hour consultation with behavioral modification with advise to lifestyle changes according to a program entitled the “Body in the Brain”, a recently published book in Norway, targeting education on how the brain and the body work together in hormonal harmony when the right diet is introduced for the right person. The patient was allowed to eat whatever she wanted in the diet plan restricted to 1200-1600 kcal, excluded from the carbohydrate list were white breads and pasta, cookies, cake, candy, sugar-sweetened sodas and drinks as well as diet sodas and diet juice. She followed the educational program related to the “Body in the Brain”[14] where she each month was given new insight into how the body and the brain worked together in a hormonally balanced way. She was also gradually introduced to healthier foods, e.g., food that was rich in tryptophan, an essential amino acid that target serotonin in the brain and indirectly impact insulin levels.  In her diet plan was a list of tryptophan rich food such as e.g.salmon, chicken, cod, tuna, apricots, broccoli, sprouts, whole grain, skimmed milk and almonds, food that was known as comfort food or mood food. The list was extended each visit and the food the patient did not like was replaced with other food items.

In her first two weeks of treatment she lost only one pound, but she reported that her blood sugar had not spiked as much as prior times after she had tried to avoid sugar and other simple carbohydrates. She admitted it was difficult to avoid these foods as she always had had a sweet tooth.  On her second visit she was educated in how the body relates to the brain in a hormonal way when certain food items are ingested. She was introduced to the amino acid tryptophan and how the tryptophan rich food would create more harmony in the gut-brain axis, increase serotonin levels and decrease cortisol and thereby improve insulin sensitivity. The education went on for 22 months and at each visit the biochemistry of food were addressed. How the food she ingested had an impact on her body and brain was a favorite topic of the visits to come.

Over the next four weeks she had lost only 1.2 kg. The visit two weeks later showed a decrease of an additional 0.7 kg, however the fat percentage in her body had not changed. Until this time, the fat lost was attributable to pure lean body mass. She was then introduced to the patented supplement consisting of Green tea extract, White kidney bean extract and Locust bean gum extract, a supplement that was sold over the counter in Norway, approved by the Norwegian Medicines Agency and also recently the ingredients were approved by the FDA in the US. She gradually lost weight each month with a simultaneous loss in fat percentage. 12 months later she had lost 21 kg of which 85% was loss in fat mass. She became less depressed, her energy level had improved, and she was still very motivated for further weight loss.

By the end of the 23 month treatment period she had lost 38 kg and the fat percentage in the body had decreased to 31.9% which was within normal limits for her age. Her blood sugar was under control. However, she was still on antidiabetics, however, her blood sugar and HbA1c was within normal limits and her hypertension was well regulated. Six months later, she was accepted for the surgery of her abdominal hernia as her fat mass was within normal range in spite of a BMI>30kg/m 2 .

The patented diet supplement with white kidney bean extract, locust bean gum and green tea extract in combination with an education program (The Body in The Brain) consisting of twenty-six outpatient clinic sessions,  resulted in a very significant weight loss, improvement in fat percentage, hypertension and blood sugar levels in an obese  woman following this program. In terms of the weight loss observed in this patient, fat was more than 75% of the total weight lost indicating a qualitative weight reduction where less than one quart of the weight lost was lean body mass[15].  The patient lost 25% more body fat of her weight lost than would predicted with lifestyle changes alone. The special designed diet program was modified accordingly in subsequent visits due to changes in the BMR. Her caloric intake was never changed to lesser than her BMR. The reason why her energy level increased and her mood improved, can very well be caused by the change in diet.,At each meal, she ate primarily foods rich in tryptophan combined with complex carbohydrates and thereby increased her serotonin levels. Several studies have shown that increased serotonin levels are related to mood elevations [16,17]. However, her improved mood and higher energy in this patient, may also be caused by the fat lost relieving the stress in the gut-brain axis. 

The amount of fat mass lost of weight lost was far more than reported in earlier studies. This is in accordance with earlier unpublished pilot studies with the diet supplement used in this case report. We believe that adding this specific supplement to this combined treatment enhanced fat loss and thereby normalized parameters associated with the metabolic syndrome. Earlier studies have shown that in severe obese individuals it is almost impossible to reach normal fat mass with lifestyle changes and behavioral modification alone. We believe that our natural supplement had both carbohydrate and lipid lowering effects on fat metabolism and also increased the fat expenditure. Moreover, we believe that the education program, The Body in the Brain  used in this three-pronged program, enhanced the weight loss. The patient understood the mechanisms in her body related to the food she ate, which increased her motivation for weight loss and prevented weight gain again as in earlier reports. Moreover, an encouraging physician at each visit may also be important for the patient to reach her goals. We cannot neglect the fact that obese patients are very sensitive to the knowledge of the physician and the way she is being encouraged on her road to weight loss.

A program like this can be a valuable method in the treatment of obesity in the future.

A three-pronged treatment paradigm that includes close physician follow-up, a well designed education program, and the addition of a dietary supplement consisting of an extract of white kidney bean, an extract of locust bean gum and an extract of green tea extract gave a substantial weight loss and a loss in fat mass towards a normal fat percentage in a severe obese person with the metabolic syndrome.

• Després JP, Lemieux I (2006) Abdominal obesity and metabolic syndrome.  Nature 444: 881-887. [ Crossref ]
• Scheen AJ (2004) Management of the metabolic syndrome.  Minerva Endocrinol 29: 31-45. [ Crossref ]
• Pittler MH, Ernst E (2004) Dietary supplements for body-weight reduction: a systematic review.  Am J ClinNutr 79: 529-536. [ Crossref ]
• Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, et al. (2013) AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation : 1- 63.
• Birketvedt GS, Aaseth J, Florholmen JR, Ryttig K (2000) Long-term effect of fibre supplement and reduced energy intake on body weight and blood lipids in overweight subjects.  ActaMedica (Hradec Kralove) 43: 129-132. [ Crossref ]
• Birketvedt GS, Langbakk B, Florholmen J (2004)A Dietary Supplement with Bean Extract Decreases Body Weight, Body Fat, Waist Circumference and Blood Pressure in Overweight and Obese Subjects. Current Topics in Nutraceutical Research 3:137-142.
• Preuss HG (2009) Bean amylase inhibitor and other carbohydrate absorption blockers: effects on diabesity and general health.  J Am CollNutr 28: 266-276. [ Crossref ]
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Editorial Information

Editor-in-chief.

Sharma S Prabhakar Texas Tech University Health Sciences Center

Article Type

Publication history.

Received: January12, 2016 Accepted: February08, 2016 Published: February 11, 2016

©2016Birketvedt GS.This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Birketvedt GS, Schou CF, Thom E(2016) A case study: Obesity and the metabolic syndrome. A threepronged program, targeting education, close follow-up and a dietary supplement, significantly decrease body weight and body fat. Integr ObesityDiabetes. 2:doi: 10.15761/IOD.1000143

Corresponding author

Medical Center for Obesity and Research, Baerum, Oslo, Norway.

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