Introduction

The obesity epidemic affects low income and minority populations disproportionately in the United States.¹ Data from the NHANES III study indicate that the prevalence of overweight individuals among Mexican-Americans aged 20-74 is nearly 70%. The incidence of clinically severe obesity in an indigent population is approximately 20%.² Obesity is also more prevalent among African-American women than Caucasian women.³ In addition, morbidity and mortality secondary to obesity-related comorbid conditions are higher among minorities than in Caucasians. For instance, the rate of stroke and coronary artery disease is 1.5 to 2.5 times higher in African American women compared to White women.⁴

Unfortunately, most indigent medical care programs do not provide resources for the management of obesity. Weight management programs in indigent populations are severely limited by cost, access to medical care, time constraints, and language barriers.

This paper summarizes our experience with a simplified obesity treatment program by implementing meal replacements as a tool for lifestyle change and weight loss in obese indigent patients. Meal replacements have been shown to be safe and effective for weight loss management in obese patients.^5-7 In addition, meal replacements are safe for use in obese diabetic patients.⁸

Obesity Management Program

The Venice Family Clinic is the largest free clinic in the United States. The clinic population includes largely working individuals without health insurance. Eighty-four percent of the patients have incomes below poverty level.

In August 2001, a nutrition clinic was started through a joint effort involving the UCLA Center for Human Nutrition and the Venice Family Clinic. The goals of the program were:

1) To implement a free nutritional program for the medical management of obesity in an indigent population consisting of medically supervised low calorie diets (1000 to 1200 cal/day), behavior modification, exercise recommendations, volunteer-directed group support, obesity workshops for patients and physicians, short-term pharmacological treatment as an adjunct to weight loss when necessary

2) To assess the effectiveness of medical obesity management in an indigent population

To date, 99 patients have been referred to the nutrition clinic. All 99 patients have been followed prospectively to assess the effectiveness of a commercially-available meal replacement plan for weight management. All patients underwent body composition measurement by bioelectrical impedance analysis at baseline and every three months subsequently.⁹

Patients were placed on a meal replacement soy protein powder (170 calories, 15 g protein). They were advised to consume one meal replacement soy protein powder for breakfast, one for lunch, and a low fat, calorie-controlled diet for dinner. The total caloric intake for each patient was 300 to 1000 calories per day below their basal metabolic rate depending on the degree of motivation of the patient to diet. The protein intake was 0.5 g - 1 g per pound of bioelectric impedance analysis-determined lean body mass, depending on the gender and the degree of activity of the patient. All patients were advised to avoid \"trigger foods\" such as nuts, cheese, pizza, salad dressing, mayonnaise, margarine, butter, red meat, fatty fish, frozen yogurt, ice cream, and pastries. Meal plans for calorie-controlled diets both in English and Spanish, incorporating the use of meal replacements and portion-controlled meals were designed for simplicity of implementation.^10,11

Patients were advised to walk for half an hour every day and/or engage in moderate weight lifting depending on the age and gender of the patient. Compliance was subjectively assessed at every visit during the follow up period.

Seventeen patients (17.2%) were placed on 25 mg Diethylproprion three times a day. The selection criteria for pharmacotherapy included the patient\'s age, comorbid conditions, and stated inability to control their appetite. Pharmacotherapy was used in accordance with the recommendations of the National Heart, Lung and Blood Institute.¹ Patients below the age of 18 were not treated with pharmacotherapy.

A support group was also developed and met every two weeks. Patients shared their difficulties in adopting new eating behaviors, discussed their coping mechanisms, and exchanged recipes. The moderator of the group, a volunteer dietitian or an exercise specialist reviewed topics on nutrition and exercise activities. There was a translator present at each of the meetings and written materials were provided both in English and Spanish.

Following counseling regarding diet and exercise by volunteer dietitians and an exercise specialist in the appropriate language, all patients were seen every two to four weeks depending on their degree of success. Patients who were not losing weight were asked to come to clinic at least once every two weeks. The obesity management program is depicted in Table 1.

Thirty-one weeks following implementation of the program, 99 patients (79 females, 20 males) had been referred to the nutrition clinic. Of the 99 patients, 21 patients dropped out of the program and 3 patients were new to the clinic and had only been seen once. The remaining 75 patients had two or more clinic visits, and their results are presented below.

Meal replacements were accepted as a strategy for weight loss in this patient population. The average weight loss at 31 weeks was 12.3?1.4 pounds (5.9?0.67 kg). Each patient made an average of 5 visits to the clinic. The mean rate of weight loss in all patients was 0.75 pounds per week. The average percentage weight loss in this group at 31 weeks was 5.5?0.6%. Sixteen patients were able to lose more than 10% excess body weight at 31 weeks follow up. All the patients able to accomplish a 10% reduction in body weight had more than 8 visits to the clinic. Patients who received Diethylproprion had similar rate of weight loss compared to those on the diet alone.

Discussion

The epidemic of obesity in the United States extends to every group in America including minorities and underserved populations. For the clinically severe obese patient (BMI >40 kg/m² or >35 kg/m² with comorbid conditions), non-surgical treatments are, in a majority of cases, unable to help patients maintain a

Acknowledgements

Slim-Fast Foods Company, Inc. of West Palm Beach, Florida kindly donated the Soy-Slim Fast meal replacements for patient use in this study. This project has been possible due to commitment of volunteer physicians and students who donate their invaluable time to the Venice Family Clinic. Many thanks to: Denise Yun MD, Jonas Hannestad MD PhD, James Arteaga MD, Scott Deshields, Debbie Wong, Sarah Dickinson, Theresa Ranftl-Clemens, Eric Wong, Grace Noh, Hyun-Woo Lee, Judith Sherman-Wolin