Gewichtsreductie

Welke interventies zijn effectief?

Victor Gerdes

Internist

Disclosure belangen

Voor bijeenkomst mogelijk Bedrijfsnamen

relevante relaties

• Sponsoring of onderzoeksgeld AstraZeneca (investigator initiated study)

• Honorarium of andere (financiële) Sprekervergoedingen: Sanofi, Bayer, Lilly

vergoeding

• Aandeelhouder nvt

• Andere relatie, namelijk team bariatrische chirurgie

Spaarne Gasthuis

Welke interventies zijn effectief?

• Bevolking Bevolking

• Eerste lijn BMI > 25

• Gespecialiseerde centra BMI > 35

Myths, presumptions and facts about obesity

Provision of meals and use of meal-replacement products promote greater weight loss

A bout of sexual activity burns 100 to 300 kcal for each person involved

The built environment, in terms of sidewalk and park availability, influences obesity

N Engl J Med 2013;368:446-54.

Myths, presumptions and facts about obesity

Provision of meals and use of meal-replacement products promote greater weight loss

A bout of sexual activity burns 100 to 300 kcal for each person involved

The built environment, in terms of sidewalk and park availability, influences obesity

N Engl J Med 2013;368:446-54.

Myths, presumptions and facts about obesity

Regularly eating (vs. skipping) breakfast is protective against obesity

Regardless of body weight or weight loss, an increased level of exercise increases health

Setting realistic goals in obesity treatment is important because otherwise patients will become frustrated and lose less weight

N Engl J Med 2013;368:446-54.

Myths, presumptions and facts about obesity

Regularly eating (vs. skipping) breakfast is protective against obesity

Regardless of body weight or weight loss, an increased level of exercise increases health

Setting realistic goals in obesity treatment is important because otherwise patients will become frustrated and lose less weight

N Engl J Med 2013;368:446-54.

Bevolking

• Scholing

• Belasting

• Aanleg van gebouwen en steden

• Werkgevers

• Producenten

• Winkels

Dieet

• Restrictie energie inname

• Samenstelling• Vet• Koolhydraat• Eiwit

• Verdeling over de dag

• Afgepaste hoeveelheid / voorverpakt

Med Clin North Am . 2018 January ; 102(1): 107–124

Med Clin North Am . 2018 January ; 102(1): 107–124

Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates

N Engl J Med 2009;360:859-73.

Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates

Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates

Physical activity vs basal metabolic rate

Lichaamsbeweging

RCT 12 maanden beweegprogramma: gemiddeld – intensief

• Interventiegroep 298 min/wk vs controlegroep 68 min/wk

• Gewichtsverlies 2,1 kg (vrouwen) en 1.7 kg (mannen)

Systematic review over aerobic exercise

• 14 trials, 1847 pt

• -1.7 (-2.29 to -1.11) kg Taille omtrek -1.95 (-3.62 to -0.29) cm

Lichaamsbeweging

• Afvallen: in principe risico voor spierkracht en skelet• Gezondheid en aantal uren zitten er dag / habitual exercise

• Ook bij gelijk gewicht voldoende bewegen gunstig• Vetpercentage > metabole effecten• Behoud spiermassa

Welk advies te geven?• Bij ernstig overgewicht oppassen voor blessure

• Lopen• Zwemmen• Fietsen

Gedragstherapie obesitas

• Aannames• Aangeleerde patronen maladaptief• Gedrag kan veranderen

Met verschillende methoden

• Aanpassen en monitoren intake

• Aanpassen en monitoren beweging

• Controleren omgeving en stimuli

• Groep of individueel

• Welk programma: voorkeur patiënt van belang

• Internet, telefoon

JAMA.2018;320(11):1172-1191

JAMA.2018;320(11):1172-1191

−2.39kg [95%CI,−2.86 to −1.93]

67 studies

n=22065

Behavioral and Psychological Strategies of Long-Term Weight Loss Maintainers in a Widely Available Weight Management Program

Obesity (2020) 28, 421-428

Randomised placebo-controlled trial of orlistat for weight loss and prevention of weight regain in obese patients

• N=743

• Orlistat 120 mg 3dd

• Hypocaloric (-600)

• Weight loss 10.2% vs 6.1% at 1 yr

Mean percentage change in bodyweight from start of single-blind lead-in until 2-year examination in orlistatand placebo groups

THE LANCET • Vol 352 • July 18, 1998

Randomized Trial of Lifestyle Modification and Pharmacotherapy for Obesity

• N=224

• Interventions• Sibutramine 15 mg alone

• 30 group sessions

• 30 group sessions icmsibutramine

• Brief therapy icm sibutramine

• 1200-1500 kcal

• 1 year follow-up

N Engl J Med 2005;353:2111-20

Phentermin / topiramate

Am J Clin Nutr 2012;95:297–308.

A Randomized, Controlled Trial of 3.0 mg of Liraglutidein Weight Management

N Engl J Med 2015;373:11-22

Weight Loss at 1 Year with High-Intensity Lifestyle Interventions or Pharmacotherapy Combined with

Low-to-Moderate-Intensity Lifestyle Counseling.

N Engl J Med 2017;376:254-66.

A Two-Year Randomized Trial of Obesity Treatment in Primary Care Practice

• Primary care

• N=390

• Follow-up 2 yrs

• Intervention• Quarterly visit• Quarterly visit + lifestyle coach every

month• Quarterly visit + lifestyle coach +

meal replacement / medication

N Engl J Med 2011; 365: 1969–1979

A Two-Year Randomized Trial of Obesity Treatment in Primary Care Practice

Figure 3. Categorical Weight Loss at 12 and 24 Months. Panel A shows the percentage of participants in each group in the intention-to-treat population who were at or below their baseline weight at months 12 and 24. (Participants for whom data on weight were missing were assumed to have a weight above the baseline weight.) Panel B shows the percentage of participants who lost 5% ormore of their baseline weight, and Panel C shows the percentage of participants who lost 10% or more of their baseline weight. (The percentage of participants who lost 5% or more of their baseline weight includes the percentage who lost 10% or more.

Nieuwe middelen

• Semaglutide

• Thermogenese

• Eetlust / verzadiging

• Micro RNA mimetica

• Microbiota / metabolieten

Combinatietherapie?

Bariatrische chirurgie

BMI > 35 icm comorbiditeit of

BMI > 40

Verschillende ingrepen

Grote spreiding effect op korte en lange termijn

N Engl J Med 2017;377:1143-55.

Endoscopic and minimally invasive technologies

Obesity Surgery (2020) 30:736–752

Endoscopic and minimally invasive technologies

Obesity Surgery (2020) 30:736–752

Pacemaker

Endoluminaal restrictief

Endoluminale bypass of sleeve

Magnetische anastomose

Endoscopische aspiratie

Welke interventies zijn effectief?

• Preventie

• Gecombineerde aanpak

• Focus op lange termijn

• Medicatie

• Bariatrische chirurgie

Toekomst?

Verbeteren bestaande mogelijkheden

Voorspellen respons

Nieuwe medicatie

Gastroscopisch en / of minimaal invasief