CHRONIC PAIN: prevent relapses

Overview

Do you weigh more than you should? If so, you're like the two-thirds of American adults who are overweight. About one in three American adults is considered to be obese. And childhood obesity is at an all-time high.

Obesity is more than a cosmetic concern. Being seriously overweight puts you at greater risk of developing high blood pressure and many other serious health risks. Ultimately, obesity can even be life-threatening. Annually in the United States, more than 300,000 deaths are linked to obesity.

The good news is that even a modest weight loss can bring health improvements. In many cases, you can accomplish this by eating healthier, exercising and changing behaviors. For people who don't respond to lifestyle changes, prescription medications and surgical techniques are available to enhance the weight-loss process.

Causes

Obesity involves having an abnormally high proportion of body fat. Doctors define obesity as having a body mass index (BMI) of 30 or higher and overweight as having a BMI of 25 or higher.

Weight is largely determined by how you balance your intake of calories from food with the energy you use in everyday activities. If you consume more calories than you use, you gain weight. Your body stores calories that you don't need for energy as fat.

Fat is important for storing energy and insulating your body, among other functions. The human body can handle carrying some extra fat, but beyond a certain point, body fat can begin to interfere with your health.

Eating too many calories and not getting enough physical activity are the main causes of obesity, especially in combination. But many factors can contribute to obesity.

 

Risk factors

Factors that increase your risk of being obese include:

• Diet. Regular consumption of high-calorie foods, such as fast foods, contributes to weight gain. High-fat foods are dense in calories. Loading up on soft drinks, candy and desserts also promotes weight gain. Foods and beverages like these are high in sugar and calories.
• Inactivity. Sedentary people are more likely to gain weight because they don't burn calories through physical activities.

§                  Psychological factors. Some people overeat to cope with problems or deal with emotions, such as stress or boredom.

§                  Genetics. If one or both of your parents are obese, your chances of being overweight are greater. Your genes may affect the amount of body fat you store and where that fat is distributed. But, your genetic makeup doesn't guarantee that you'll be obese.

§                  Age. As you get older, you tend to be less active. In addition, the amount of muscle in your body tends to decrease with age. This lower muscle mass leads to a decrease in metabolism. These changes also reduce calorie needs. If you don't decrease your caloric intake as you age, you'll likely gain weight.

§                  Cigarette smoking. Smokers tend to gain weight after quitting. This weight gain may be partially due to nicotine's ability to raise the rate at which your body burns calories (metabolic rate). When smokers stop, they burn fewer calories. Smoking also affects taste; quitting smoking makes food taste and smell better. Former smokers often gain weight because they eat more after they quit. However, cigarette smoking is still considered a greater threat to your health than is extra weight.

§                  Pregnancy. During pregnancy a woman's weight necessarily increases. Some women find this weight difficult to lose after the baby is born. This weight gain may contribute to the development of obesity in women.

§                  Medications. Corticosteroids and tricyclic antidepressants, in particular, can lead to weight gain. So can some high blood pressure and antipsychotic medications.

§                  Medical problems. Uncommonly, obesity can be traced to a medical cause, such as low thyroid function, excess production of hormones by the adrenal glands (Cushing's syndrome) or other hormonal imbalances, such as polycystic ovary syndrome. A low metabolic rate is rarely a cause of obesity. A medical problem, such as arthritis, can also lead to decreased activity, which can result in weight gain.

§                  Alcohol. Drinking alcohol adds calories to your diet — just one regular beer is about 150 calories. If you don't cut back somewhere else, adding just one beer daily could cause a weight gain of more than one pound a month. Additionally, excessive drinking can stimulate your appetite and make you less likely to control portion sizes.

When to seek medical advice

How do you know whether you need to lose weight for medical reasons? These evaluations can help provide the answer:

§                  Body mass index (BMI). The BMI is a formula that uses weight and height to estimate body fat and health risks. If your BMI is between 19 and 24, you're considered in a healthy weight range for your height. If your BMI is between 25 and 29, you're considered overweight. And, if the figure is 30 or greater, you're considered obese and should talk to your doctor about losing weight for your health.

§                  Waist circumference. If you carry most of your fat around your waist or upper body, you may be referred to as apple shaped. If you carry most of your fat around your hips and thighs or lower body, you may be referred to as pear shaped. Generally, when it comes to your health, it's better to have the shape of a pear than the shape of an apple. If you have an apple shape — a potbelly or spare tire — you carry more fat in and around your abdominal organs. Abdominal fat increases your risk of many of the serious conditions associated with obesity. Women's waist measurements should be less than 35 inches. Men's should be less than 40 inches. If you have a large waist circumference, talk to your doctor about weight loss.

Talking to your doctor openly and honestly about your weight is one of the best things you can do for your health. The more your weight increases, the more medical problems you may face.

Also, talk to your doctor if you have weight-related medical conditions, such as high blood pressure, high blood cholesterol, diabetes and arthritis. These health conditions may improve if you're able to lose weight.

Screening and diagnosis

Your doctor can help you determine whether you need to lose weight and, if so, how much.

In addition to evaluating your BMI and waist circumference, your doctor can review your medical history, which helps reveal how dangerous excess fat is to your health. Do you smoke, drink alcohol or live with a high level of stress? In combination with these behaviors, excess weight can have even greater health implications.

Your doctor can also assess your current health. You may have a health problem that would improve if you lost weight or that requires treatment beyond weight loss.

Complications

If you're obese, you're more likely to develop a number of potentially serious health problems. These may include:

§                  High blood pressure. As you put on weight, you gain mostly fatty tissue. Just like other parts of the body, this tissue relies on oxygen and nutrients in your blood to survive. As demand for oxygen and nutrients increases, the amount of blood circulating through your body also increases. More blood traveling through your arteries means added pressure on your artery walls. Weight gain also typically increases the level of insulin, a blood-sugar-controlling hormone, in your blood. The increase in insulin is associated with retention of sodium and water, which increases blood volume. In addition, excess weight often is associated with an increase in your heart rate and a reduction in the capacity of your blood vessels to transport blood. All of these factors can increase blood pressure.

§                  Diabetes. Obesity is a leading cause of type 2 diabetes. Excess fat makes your body resistant to insulin, the hormone that helps your body maintain a proper level of a sugar (glucose) in your blood. If your body is resistant to insulin, your blood sugar is high — which isn't good — and leads to negative health effects.

§                  Abnormal blood fats. A diet high in saturated fats — red meat and fried foods, for example — can lead to obesity as well as elevated levels of low-density lipoprotein ("bad") cholesterol. Obesity is also associated with low levels of high-density lipoprotein ("good") cholesterol and high levels of triglycerides. Triglycerides are the form in which most fat exists in food as well as in your body. Over time, abnormal blood fats can contribute to atherosclerosis — the buildup of fatty deposits in arteries throughout your body. Atherosclerosis puts you at risk of coronary artery disease and stroke.

§                  Coronary artery disease. This is a form of cardiovascular disease. It results from the buildup of fatty deposits in arteries that supply your heart. Over time these deposits can narrow your heart's arteries, so less blood flows to your heart. Diminished blood flow to your heart can cause chest pain (angina). Complete blockage can lead to a heart attack.

§                  Stroke. Obesity is associated with atherosclerosis — the buildup of fatty deposits in arteries throughout your body, including arteries in your brain. If a blood clot forms in a narrowed artery in your brain, it can block blood flow to an area of your brain. The result is a stroke. Being obese raises your risk of a stroke.

§                  Osteoarthritis. This joint disorder most often affects the knees, hips and lower back. Excess weight puts extra pressure on these joints and wears away the cartilage that protects them, resulting in joint pain and stiffness.

§                  Sleep apnea. This serious condition causes a person to stop breathing for short periods during sleep and to snore heavily. The upper airway is blocked during sleep, which results in frequent awakening at night and subsequent drowsiness during the day. Most people with sleep apnea are overweight, which contributes to a large neck and narrowed airways.

§                  Cancer. Many types of cancer are associated with being overweight. In women, these include cancers of the breast, uterus, cervix, ovaries and gallbladder. Overweight men have a particularly higher risk of cancers of the colon, rectum and the prostate.

§                  Fatty liver disease. When you're obese, fats can build up in your liver. This fatty accumulation can lead to inflammation and scarring of the liver. Such scarring can cause cirrhosis of the liver, even if you're not a heavy alcohol drinker.

§                  Gallbladder disease. Because overweight people may produce more cholesterol, which can be deposited in the gallbladder, the risk of gallstones is higher in obese people. Fast weight loss — more than 3 pounds a week — also can increase the risk of gallstones.

Obesity can also contribute to gout, a joint disorder.

Treatment

The good news is that losing even modest amounts of weight can lower your blood pressure, reduce your risk of cardiovascular disease and stroke, improve glucose control in diabetes, improve signs and symptoms of osteoarthritis and sleep apnea, and lower your risk of cancer.

The amount of weight you need to lose to improve your health may be much less than what you feel you need to lose. The first goal in dealing with obesity is to achieve and maintain a healthier weight.

That usually requires reducing your weight by approximately 5 percent to 10 percent. That means that if you weigh 200 pounds and are obese by BMI standards, you would need to lose at least 10 to 20 pounds. That doesn't mean you should stop there. But it's a place to start. Slow and steady weight loss of 1 or 2 pounds a week is considered the safest way to lose weight and the best way to keep it off.

In many cases, losing weight can be accomplished by committing to eating a healthier diet, exercising and changing behaviors. Other treatments for obesity include prescription medications and surgery.

Dietary changes
Consuming fewer calories is an important factor for successful weight loss.

The number of calories you need to maintain weight each day depends on several factors, including your age and activity level. Ask your doctor to help you determine your calorie goals to lose weight. He or she may recommend that you also work with a dietitian or a reputable weight-loss program.

Crash diets to reduce calories aren't recommended because they can cut so many calories and nutrients that they lead to other health problems, such as vitamin deficiencies. Fasting isn't the answer, either. Most of the weight you initially lose is from water, and it's not good for your body to go without food for extended periods.

Very low calorie liquid diets are sometimes prescribed as an intervention for seriously obese people. These mainly liquid diets, such as Medifast or Optifast, provide about 800 calories a day — most adults consume roughly 2,000 to 2,500 calories a day. While people are usually able to lose weight on these very low calorie diets, most people regain the weight just as quickly when they stop following these diets.

Over-the-counter liquid meal replacements, such as Slim-Fast, also cut calories. These plans suggest that you replace one or two meals with their product — a low-calorie shake — then eat snacks of vegetables and fruits and a healthy, balanced third meal that is low in fat and calories. This can be as effective as a traditional calorie-controlled diet.

To lose weight and keep it off, eat moderate amounts of nutrient-rich, low-fat, low-calorie foods. Follow these fundamentals of healthy eating:

§                  Think 'energy density.' Energy density is the number of calories in a given volume of food. Eat a food that's energy dense, such as fat, and you can't eat much of it without consuming a lot of calories. On the other hand, eat a food with low energy density, including most vegetables and some fruits, and you can consume a huge amount for few calories. For example: A tablespoon of butter has the same number of calories as 20 cups of leaf lettuce. Which would leave you feeling fuller? Choose low-energy-dense foods, which include a lot of fresh fruits and vegetables.

§                  Choose healthy foods. Healthy foods include vegetables, fruits, grains and lean sources of protein, including beans, fish, low-fat dairy products and lean meats. These foods optimize nutrition and taste and promote a healthy weight. Eat a variety of healthy foods in lieu of junk foods.

§                  Choose the right carbohydrates. Nutrition experts generally agree that 45 percent to 65 percent of your total daily calories should come from carbohydrates. But be choosy about those you eat. Steer away from simple carbohydrates, such as table sugar and other sweeteners, and limit fruit juice, which is a type of carbohydrate concentrated in calories. Instead, try to eat plenty of complex, high-fiber carbohydrates, such as whole-grain bread, brown rice, and other grains, such as oatmeal.

§                  Cut back on sweets. Limit candies, cakes, cookies, muffins, pies, doughnuts and frozen desserts. They're a large source of calories. Better dessert choices include angel food cake, vanilla wafers, fig-bar cookies, low-fat frozen yogurt, sorbet or sherbet.

§                  Reduce fat. Because fat has more than twice the calories of carbohydrate and protein ounce for ounce, reducing the fat content of your diet is an important way to cut calories. Foods high in fat include most fast foods, pastries, red meats, full-fat dairy products, oils, margarine, butter, salad dressings and mayonnaise. Current dietary guidelines recommend that healthy Americans get between 20 percent and 35 percent of total calories from fat, with less than 10 percent of your total calories coming from saturated fat sources.

§                  Watch portion sizes. Serving sizes may be smaller than you think. A single 2 1/2-ounce serving of fish or poultry, for example, is about the size of a deck of cards. A 2-ounce serving of cheese or 1 teaspoon of butter is about the size of four dice. A small apple or a medium orange are comparable in size to a tennis ball. A hockey puck is about the size of one-half a bagel or a slice of whole-grain bread. It's especially important to watch serving sizes when eating out because many restaurants serve oversized portions.

§                  Count calories. Read food labels. Foods that are low in fat can sometimes be very high in calories. Processed foods — most products other than fresh foods — often have hidden fat and sugar. Cut back on sugary soft drinks. They're high in calories.

 

Healthy Weight Pyramid
To help simplify what you should eat, Mayo Clinic has developed the Mayo Clinic Healthy Weight Pyramid — a tool to help you manage your weight and improve your health.

The strengths of the Mayo Clinic Healthy Weight Pyramid are:

§                  It emphasizes weight management.

§                  Fruits and vegetables are located at the bottom of the Mayo Clinic pyramid as opposed to the bread, cereal and starch group because these foods are very low in calories and high in health-enhancing properties. The Mayo Clinic pyramid doesn't limit the intake of whole, fresh or frozen fruits and vegetables.

§                  The Mayo Clinic Healthy Weight Pyramid emphasizes healthier choices within each of the five food groups. That's because not all foods within a group provide the same health benefits even though they may contain the same number of calories.

§                  Daily physical activity is located in the middle of the Mayo Clinic pyramid to emphasize its central role in both managing weight and improving health.

Mayo Clinic recommends that you talk with your doctor before making any changes in your eating habits.

Group weight-loss programs
Even when you decide the best way to lose weight comes from eating low-calorie foods in moderate amounts, you don't have to go it alone. Commercial group programs can support your efforts, giving you eating plans and reinforcement from others on the same path.

Here's a sampling of group approaches:

§                  Overeaters Anonymous. Are you a compulsive overeater? According to Overeaters Anonymous (OA), you're in the best position to decide whether your eating is out of control. If the amount of food you eat has become unmanageable, Overeaters Anonymous can help. This is a nonprofit program designed for people who regard themselves as recovering compulsive overeaters. The approach is identical to that of Alcoholics Anonymous, with meetings focusing on 12 steps and 12 traditions. Its goal is to help members avoid compulsive overeating and to offer assistance to others who still suffer. This program is supported by donations only.

§                  TOPS (Take Off Pounds Sensibly). Mainly a support group, TOPS doesn't tell you what foods to eat or how much to consume, nor does it watch over your exercise levels. It's a nonprofit, noncommercial group that's run solely by volunteers. TOPS charges a low annual membership fee. Weekly meetings begin with a confidential weigh-in, and then include a program from a TOPS leader or member, or perhaps a doctor, dietitian, psychologist or other expert. Participants can share their successes and challenges in sessions afterward. Before getting started, TOPS urges you to see your doctor for food and exercise plans as well as an appropriate goal weight. The group does recommend an exchange dietary plan and publishes a healthy lifestyle guide that includes a full description of how to use the plan.

§                  Weight Watchers. Weight Watchers believes in a healthy, comprehensive weight management program that includes plans for food, activity and behavior modification. For a fee, you attend a weekly meeting for a weigh-in, information or activity session, and supportive conversation. The program involves a three-step approach encompassing the foods you eat, your activity levels and the use of specific strategies that promote long-term healthy weight. There are no forbidden foods. The initial focus is on a 10 percent reduction in your weight. Once you reach that goal, you receive instruction and encouragement for continued weight loss. Eventually you reach your proper, healthy weight, and the focus moves to maintenance.

Individual weight-loss programs
Figuring out how you're supposed to eat to lose weight can be difficult, even if you have a plan. Busy schedules can preclude involved meal preparation or even keep you from trying new recipes. In those cases, calling on companies that will prepare everything for you may deserve consideration. Remember, however, that these suppliers can be expensive. Some examples:

§                  Jenny Craig. This plan started in 1983 by providing its clients with frozen meals. The company has since branched into cookbooks and programs that encourage clients to make food choices from readily available foods, as well as an at-home program for people who don't live near an established center. Jenny Craig also encourages long-term weight loss through exercise, stress reduction and individual support. You can receive personal consultations over the telephone. Using frozen meals is convenient, and the meals contain the right proportion of fat, carbohydrate and protein.

§                  NutriSystem. NutriSystem also delivers frozen meals to your door for a set price per week. You select your meals, as well as desserts or snacks. Meals are prepared in low-calorie portions that NutriSystem deems optimal for vitamins, minerals and other nutrients. You can also choose from among NutriSystem's additional products, such as salad dressings, crackers and beverages. You still need to shop for fresh produce, however.

Popular diets
Among the many popular diets in circulation are:

§                  The Atkins diet. Robert Atkins, M.D., was a pioneering proponent of a high-protein, low-carbohydrate diet back in the 1970s when his "Dr. Atkins' Diet Revolution" hit the bookstores. His ideas went out of vogue with the low-fat trend in the 1990s. However, the diet was recently popular again, though its popularity appears to be declining. The Atkins diet espouses the idea that carbohydrates promote insulin production, which leads to weight gain and other health risks. The Atkins diet, therefore, limits carbohydrates to 20 to 40 grams a day initially. Most grains, beans, fruits, breads, pastas and vegetables are excluded. You can eat meat, eggs, cheese, butter and cream on the Atkins diet. Without enough dietary carbohydrates, your body begins to burn its stored carbohydrates for energy — which releases a lot of water weight. Your body also starts burning some fat, but not as efficiently as exercise would. Burning fat without carbohydrates creates byproducts called ketones, which build up in your bloodstream. These will be processed through your kidneys before they're eliminated. Ketones do suppress appetite, but they can also cause fatigue and nausea. Some people may experience a greater initial weight loss on the Atkins diet. However, after one year, there was no major difference in weight loss, compared with other popular weight-loss plans. The long-term health effects of this diet are unknown and potentially risky.

§                  The Zone. Compared with Dr. Atkins, Barry Sears, Ph.D., author of "The Zone," is downright permissive when it comes to carbohydrates. Dr. Sears claims the key to successful weight loss is a diet in which every meal has a carbohydrate-to-protein ratio of 4-to-3. For overweight people, he recommends caloric proportions of 40 percent carbohydrate, 30 percent protein and 30 percent fat. With these proportions, says Dr. Sears, dieters experience less hunger, increased energy, peak physical performance, improved mental focus and decreased illness. The Zone diet's thrust is to sustain a specific level of the hormone insulin, an important regulator of carbohydrate metabolism. Maintaining the right levels of hormones, according to Dr. Sears, contributes to the balancing of eicosanoids, which are hormone-like substances derived from polyunsaturated fatty acids. The best way to enter "the zone," says Dr. Sears, is by preserving your eicosanoid balance. What's lacking, however, is evidence that eicosanoids are primarily responsible for diseases or that disease risk can be manipulated through changing eicosanoids in the diet. People will lose weight if they follow the prescribed diet in the book because it's low in total calories and emphasizes fruits and vegetables. A typical Zone diet consists of 1,000 to 1,400 calories a day.

§                  South Beach Diet. This diet, developed by Arthur Agatston, M.D., is basically a modified Atkins program. It isn't as restrictive in carbohydrates as the Atkins diet, except during the first two weeks of the diet. After the first two weeks, the South Beach Diet definitely restricts refined carbohydrates but allows whole grains, some fruits and vegetables and other generally healthy choices. As with the Atkins diet, the initial weight loss may not make much of a difference in the long run.

§                  Sugar Busters. When you consider that Americans each consume nearly 3 pounds of sugar a week, the premise of Sugar Busters, "Cut sugar to trim fat," may seem like one whose time has come. But the concept — which lumps in whole foods such as potatoes, corn and carrots with refined sugars found in cakes, candies and sodas — goes too far. Cutting back on sugar is only one aspect of healthy dietary changes. Without making any other nutritional alterations, and particularly when encouraging the intake of saturated fat and decreasing beneficial vegetables, this diet is unlikely to help you lose weight — or at least keep it off over the long term.

§                  Grapefruit diet. Although there are many versions of this plan — one even erroneously calls itself the Mayo Clinic Diet — all require you to eat half a grapefruit before every meal to reap the benefits of the fruit's so-called fat-burning enzymes. Calories typically are limited to fewer than 800 a day, although some versions require that you eat until you are full. Grapefruit has no fat, is low in calories and sodium, and is packed with vitamin C. But the very low calories — and deficits in protein, fiber and several important vitamins and minerals — can make this diet dangerous.

§                  Cabbage soup diet. What could be simpler? Eat as much cabbage soup as you want for seven days, and the pounds melt away. Other foods, too, are prescribed during the weeklong program, including potatoes, fruit juices and some vegetables. The only problem is that cabbage soup proponents report feeling lightheaded and weak because the diet is too low in protein, vitamins and complex carbohydrates. You may lose weight, but you'll probably be too queasy to enjoy it, plus it will likely come back as quickly as it came off.

Fad diets like these and others promote quick-and-easy weight loss. You may lose the weight quickly and relatively easily, but you'll gain it back. Fad diets don't offer a permanent, healthy solution to the problem of obesity.

Increased physical activity
Another way to lose weight is to increase physical activity.

Adding physical activity to your life doesn't mean you have to wear a sweat suit every day. A few minutes of walking or stair climbing can be as good for you as structured exercise. Here are some other simple ways to add more activity to your day:

§                  Take the stairs — not the elevator.

§                  Park in the farthest spot in the parking lot.

§                  Walk or bike to work or to the store.

§                  Walk during your lunch hour.

§                  Play with your children instead of watching them play.

§                  Walk with your family after dinner.

§                  Do weekend chores the physical way — use a push mower to mow the lawn or wash your car manually.

§                  Buy an exercise bike and pedal during TV shows or while talking on the phone.

§                  Use a pedometer and try to increase the number of steps you walk each day.

Even fidgeting helps burn calories. A Mayo Clinic study found that people who fidget, change their posture and periodically get up and move around burn as much as an extra 350 calories a day compared with more sedentary people. Those calories could translate to a loss of more than 30 pounds over the course of a year, which means that even a little activity throughout the day can add up and help promote a healthy weight.

In addition to becoming more active in your daily life, talk to your doctor about devising a structured exercise plan. Ideally, an exercise plan to help you lose weight should include regular aerobic exercise, such as walking, and strength training, such as lifting weights.

If you're obese, particularly if you're unfit and have health problems, check with your doctor before starting an exercise program.

Behavior change
To lose weight and keep it off, you need to make changes in your lifestyle.

There's more to changing your lifestyle than choosing different foods and putting more activity into your day. It also involves changing your approach to eating and activity, which means changing how you think, feel and act.

Research has demonstrated that a number of tools and tips are effective in helping you change. Follow these tips for change:

§                  Motivate yourself. No one can make you lose weight. In fact, increased external pressure — often from people close to you — may only make matters worse. Likewise, trying to lose weight to satisfy someone else rarely works either. Make diet and exercise changes to please yourself.

§                  Make lifestyle changes a priority. As you're planning to launch new weight-related lifestyle changes, make sure you've resolved other pressing problems in your life. It takes a lot of energy to change habits, and you want to be sure you're focused on the matter at hand.

§                  Have a plan. Work out a strategy that will gradually change the habits and attitudes that may have undermined your past efforts to lose weight. Choose a definite start date. Consider how often and how long you will exercise. Determine a realistic eating plan that includes plenty of water, fruits and vegetables. Write everything down: When and where will you do the steps in your plan? How will your plan fit into your schedule? What are the potential roadblocks, and how will you deal with them?

§                  Set small goals. Remember that you're in this for the long haul. You're making lifestyle changes, and the goals you've written down are your first baby steps in that direction. Anything you undertake too intensely or too vigorously will often become uncomfortable, and you're more likely to give it up.

§                  Surround yourself with good examples. As you set your goals, it helps to surround yourself with good examples. Magazines such as "Health," "Shape" and "Cooking Light" include plenty of real-life stories, healthy and easy recipes, exercise tips and interesting facts about fitness. Even if you eat meat, a publication such as "Vegetarian Times" can provide a wealth of low-fat recipes.

§                  Avoid food triggers. Distract yourself from your desire to eat with something positive, such as calling a friend. Practice saying no to unhealthy foods and big portions. Eat when you're actually hungry — not when the clock says it's time to eat. When you eat, focus on eating. Serve your meals on smaller plates to make less food seem like more. In general, store food out of sight and don't keep junk foods around.

§                  Keep a record. Ask your doctor how often you should weigh yourself as you work to lose weight. Your doctor may also recommend that you keep a food and activity diary periodically, so you can reinforce good habits and discover any behaviors that you may need to improve. Remember that success isn't defined only by actual weight lost. In fact, be sure to track other important health parameters such as blood pressure, cholesterol levels and overall fitness.

§                  Focus on the positive. Rather than focusing on what you can't eat, focus on what you can eat. Look at what new tastes and activities you can discover that will enhance your health.

§                  Don't give up. So much in American culture conspires to make and keep you overweight. You will have setbacks. Don't expect perfection. But don't give up. Use relapses to get back on track. Motivate yourself with healthy, nonfood rewards when you reach goals.

Dealing with obesity may mean taking a hard look at how you live and making some tough changes. It may be helpful to talk to a weight-loss specialist or others trying to lose weight. They may be able to help you think of food and exercise in a new light.

Medications for weight loss
Prescription weight-loss drugs aren't for people who just want to lose a few pounds for cosmetic reasons. They're for people with a BMI of 30 or higher or for those with a BMI of 27 or greater who have health problems that would likely improve with weight loss.

The two main prescription weight-loss medications are:

§                  Sibutramine (Meridia). This drug changes your brain chemistry, making you feel full more quickly. Though Meridia generally helps you lose more weight than you could through diet and exercise alone, it's no magic bullet. Studies have shown that after a year, Meridia users lost an average of about 10 pounds more than did people simply following a low-calorie diet and taking a placebo. Side effects can include increased blood pressure, headache, dry mouth, constipation and insomnia.

§                  Orlistat (Xenical). This drug inhibits the absorption of fat in your intestines. It blocks the action of the enzyme lipase in your digestive tract. Lipase breaks down dietary fat so that your body can absorb it. Orlistat can prevent the absorption of up to 30 percent of dietary fat. Unabsorbed fat is eliminated in the stool. Orlistat may also improve weight loss by discouraging you from eating an excessive amount of fat. Side effects associated with the drug include oily and frequent bowel movements. Side effects are generally made worse by increased fat intake — but improve with decreased fat intake. Average weight loss with Xenical is modest and similar to what you could expect with Meridia. Because Xenical blocks absorption of some nutrients, your doctor will recommend that you also take a multivitamin.

If you're among those who can benefit from weight-loss medication, you'll likely need to take it indefinitely. When drug treatment is stopped, much or all of the excess weight generally returns.

Even if you qualify for weight-loss drug therapy, the drugs might not work for you. And, if they do work, their effects tend to level off after six months of use.

Some weight-loss drugs have been pulled from the market because of health risks. Until the fall of 1997, one of the most popular prescriptions for weight loss was a combination of appetite suppressants known as fen-phen (fenfluramine and phentermine). This combination of medications helped many people lose weight. But it was pulled from the market after a study found that some people taking these combined drugs experienced heart valve damage.

Over-the-counter products
Over-the-counter (OTC) diet products promise to help you shed pounds by raising your metabolism or suppressing your appetite. Their side effects, however, can be dangerous.

Here's a look at some of the more popular OTC diet medications and what they will and won't do for you:

§                  Ephedra (ma-huang). One of the most popular OTC weight-loss products has been Metabolife, an herbal dietary supplement. There are similar products, but the main ingredient is ephedra. Ephedra is used in asthma medicine. It's also used to make the street drug methamphetamine, commonly known as speed. Chemically, there's only a slight difference between methamphetamine and ephedrine, the synthetic form of ephedra. This drug can slightly suppress your appetite. However, it can also cause high blood pressure, heart rate irregularities, insomnia, nervousness, tremors, seizures, heart attacks, strokes and death. In late December 2003, the Food and Drug Administration (FDA) announced the ban of ephedra from the marketplace because of health concerns.

§                  Chitosan. This is a dietary supplement made from chitin, a starch found in the skeleton of shrimp, crab and other shellfish. Because chitosan (KI-to-sun) isn't digested, it passes through your intestinal tract unabsorbed, so it adds no calories. The chemical nature of chitosan makes it bind with fatty foods you eat, removing some of this fat from your body rather than allowing it to be absorbed. Several studies, all conducted by the same researchers, found a slight advantage to chitosan over a placebo. However, three later randomized trials conducted by different research teams failed to find a difference in weight loss between chitosan and a placebo.

§                  Chromium. Chromium may be included in some weight-loss products because it may affect carbohydrate and fat metabolism. Several small studies have failed to find any benefit from taking chromium, however. Also, there's concern that chromium could cause serious side effects, such as kidney damage, especially when taken in large doses.

§                  Garcinia (hydroxycitric acid). A common ingredient in herbal weight-loss products, hydroxycitric acid comes from a plant native to India: Garcinia cambogia. A study in the "Journal of the American Medical Association" in 1998 found the herb ineffective for weight loss.

§                  St. John's wort. This is an herbal medicine derived from the Hypericum perforatum plant purported to help relieve depression. It's also found in some weight-loss medications, but it hasn't been proved effective for weight loss, and it can interact with some prescription medications.

§                  5-hydroxytryptophan (5-HTP). This extract from a plant seed contains a contaminant linked to a rare and potentially deadly blood disorder. Chemically, 5-HTP is closely related to L-tryptophan, a dietary supplement banned in 1990 after researchers found the same contaminant that has since been discovered in 5-HTP.

§                  Herbal laxatives and diuretics. They cause you to lose water, and thus lose weight, but not fat. They can lower your potassium levels, causing heart and muscle problems. Also, if you use laxatives too often, your bowels start depending on them.

§                  Caffeine. If you exercise and eat a low-fat diet, consuming large amounts of caffeine or other stimulants may slightly enhance weight loss. But taken in large doses, caffeine can cause jitters, irritability, insomnia and high blood pressure. And if combined with other stimulants, the side effects may be more serious.

§                  Pyruvate. Pyruvate, in the form of pyruvic acid, is found in the body during digestion. Pyruvate supplements seem safe, but claims of boosting metabolism, decreasing appetite and aiding in weight loss aren't well supported.

People tend to view OTC drugs and herbs less seriously than they do prescriptions and often take too much or mix them with other drugs. Also, because the manufacturing of herbs is unregulated by the FDA, you can't be sure what you're getting.

If you're troubled by your weight, talk to your doctor. OTC diet drugs can't help you with anything beyond short-term, temporary weight loss — if that. These diet products are more harmful than helpful.

Surgery for weight loss
If you've tried diet and exercise to lose weight but remain seriously obese (a BMI of 35 or higher) and have weight-related health problems as a result, weight-loss surgery (bariatric surgery) may be the next best step.

The most common operations fall into one of two categories:

§                  Stomach surgery. The first uses a band or staples to create a small pouch at the top of your stomach, where food enters from your esophagus — the tube from your mouth to your stomach. The stomach pouch can hold only about an ounce or two of food, though this can later expand to several ounces. After the operation, you can eat only small portions of food at a time without feeling nausea or discomfort.

§                  Stomach surgery plus intestinal bypass. The second type of surgery also creates a small pouch, but adds a bypass around part of your small intestine, where most of the calories from foods that you eat are absorbed. This surgery does double duty. It reduces what you can eat, and it reduces the calories your body absorbs.

Here are some of the specific operations, representing these two categories:

§                  Vertical banded gastroplasty (VBG). This is an example of the first category of weight-loss surgery, which is designed to partition the stomach into two parts. Using a surgical stapler, the surgeon divides your stomach into upper and lower sections. The upper pouch is small and empties into the lower pouch, which is the rest of your stomach. At the dime-sized opening where the upper pouch empties into the rest of your stomach, the surgeon wraps the tissue with a piece of nonexpandable plastic. This banding of the opening between the upper stomach pouch and the rest of the stomach helps prevent the opening from stretching.

§                  Gastric bypass. This weight-loss surgery is an example of the second category of surgery — creating a small pouch and adding a bypass around part of your small intestine. The surgeon staples your stomach all the way across the top, leaving a tiny pouch. Then the surgeon cuts the small intestine and sews a part of it directly onto the upper pouch. This redirects the food, bypassing most of your stomach and the first section of your small intestine. Food flows directly into the middle section of your small intestine, limiting your body's ability to absorb calories. Even though food never enters the lower part of your stomach, the stomach stays healthy and continues making digestive juices that flow into your small intestine. Some surgeons can perform gastric bypass by inserting laparoscopes — tiny, tubular instruments with a small camera attached — through small incisions made in the abdomen. This is called laparoscopic gastric bypass. Performing the operation laparoscopically can help decrease your hospital stay and lead to a quicker recovery. There also appear to be fewer wound-related problems with laparoscopic gastric bypass than with the traditional "open" gastric bypass. Not everyone is a candidate for laparoscopic gastric bypass, so consult your doctor.

When appropriate, weight-loss surgery can result in dramatic improvements in weight and health. In the first year or two, most people lose up to 50 percent of their excess weight. Generally, those who follow dietary and exercise recommendations keep most of that weight off long term.

However, weight-loss surgery does have side effects. Complications such as pneumonia, blood clots and infection can occur with any type of surgery. Rapid weight loss can result in gallstones in about one-third of people who have obesity surgery. A hernia or weakness, which may require surgery to correct, may develop at the site of your incision.

At first after surgery, if you eat too much or too fast, you'll experience nausea and other symptoms, called dumping syndrome. Over time, you'll be able to increase your food intake.

Surgery for weight reduction isn't a miracle procedure, and there are side effects and potential complications. Though you can expect to lose weight and keep it off, you still need to eat healthy foods and remain active.

Liposuction: Not a weight-loss plan
Liposuction is cosmetic surgery, not a weight-loss plan. The surgeon inserts a narrow tube under your skin through tiny incisions, and then suctions out fat cells. It's most commonly used to trim the outer thighs, abdomen or love handles. Though liposuction has improved to allow surgeons to remove some fat during the procedure, this body-shaping procedure isn't a treatment for obesity.