The [[Cochrane Collaboration]] found that exercising alone led to limited weight loss. In combination with diet, however, it resulted in a 1 kilogram weight loss over dieting alone. A 1.5kg loss was observed with a greater degree of exercise. Even though exercise as carried out in the general population has only modest effects, a [[Dose-response relationship|dose response curve]] is found and very intense exercise can lead to substantial weight loss. During 20 weeks of basic military training with no dietary restriction, obese military recruits lost 12.5kg. High levels of physical activity seem to be necessary to maintain weight loss. A [[pedometer]] appears useful for motivation. Over an average of 18-weeks of use, physical activity increased by 27% resulting in a 0.38 decrease in BMI.
Signs that encourage the use of stairs as well as community campaigns have been shown to be effective in increasing exercise in a population. The city of [[Bogota]], [[Colombia]], for example, blocks off 113km of roads every Sunday and on holidays to make it easier for its citizens to get exercise. These [[pedestrian zone]]s are part of an effort to combat chronic diseases, including obesity.
There is evidence that exercise alone is not sufficient to produce meaningful weight loss, but combining dieting and exercise provide the greatest health benefits and weight loss on the long term.
</div>
<div lang="en" dir="ltr" class="mw-content-ltr">
==減量プログラム==
==Weight loss programs==
{{Anchor|Weight loss programs}}
Weight loss programs involve lifestyle changes including diet modifications, physical activity and behavior therapy. This may involve eating [[portion size|smaller meals]], cutting down on certain types of food and making a conscious effort to exercise more. These programs also enable people to connect with a group of others who are attempting to lose weight, in the hopes that participants will form mutually motivating and encouraging relationships. Since 2013, the United States guidelines recommend treating obesity as a disease and actively treat obese people for weight loss.
A number of popular programs exist including [[WW International|Weight Watchers]], [[Overeaters Anonymous]] and [[Jenny Craig, Inc.|Jenny Craig]]. These appear to provide modest weight loss (2.9kg) over dieting on one's own (0.2kg) over a two-year period, similarly to non-commercial diets. As of 2005, there was insufficient scientific evidence to determine whether Internet-based programs produce effective weight loss.
[[:en:Government of the People's Republic of China|中国政府]]は、肥満の子供たちが運動を強化するために通う「脂肪農場」を多数導入し、学校で1日1時間の運動やスポーツをすることを義務付ける法律を可決した（[[Obesity in China/ja|中国における肥満]]を参照）。
The [[Government of the People's Republic of China|Chinese government]] has introduced a number of "fat farms" where obese children go for reinforced exercise and has passed a law which requires students to exercise or play sports for an hour a day at school (see [[Obesity in China]]).
In a structured setting with a trained therapist, these interventions produce an average weight loss of up to 8 kg in 6 months to 1 year, and 67% of people who lost greater than 10% of their body mass maintained or continued to lose weight one year later. There is a gradual weight regain after the first year of about 1 to 2 kg per year, but on the long-term this still results in weight loss. Risk factors for cardiovascular disease and for diabetes are reduced for several years after taking part in a weight management programme, even if people regained weight.
Attending group meetings for [[Weight loss|weight reduction]] programmes rather than receiving one-on-one support may increase the likelihood that obese people will lose weight. Those who participated in groups had more treatment time and were more likely to lose enough weight to improve their health. Study authors suggested that one explanation for the difference is that group participants spent more time with the clinician (or whoever delivered the programme) than those receiving one-on-one support.
Comprehensive diet programs, providing counseling, targets for calorie intake and exercise, may be more efficient than dieting without guidance ("self-help"), although the evidence is very limited. Following comprehensive lifestyle modifications, the average maintained weight loss is more than 3kg or 3% of total body mass, and could be sustained for five years, and up to 20% of the individuals maintain a weight loss of at least 10% (average of 33 kg). There is some evidence that fast weight loss produce greater long-term weight loss than gradual weight loss. Moderate on-site comprehensive lifestyle changes produce a greater weight loss than usual care, of 2 to 4 kg on average in 6 to 12 months. High-intensity comprehensive programs usually yield more weight loss than moderate or low-intensity, with about 35% to 60% of overweight individuals maintaining more than 5 kg weight loss after 2 years.
</div>
<div lang="en" dir="ltr" class="mw-content-ltr">
[[:en:National Institute for Health and Care Excellence|NICE]]は、商業的な体重管理団体が承認されるために満たすべき一連の必須基準を考案した。
The [[National Institute for Health and Care Excellence|NICE]] devised a set of essential criteria to be met by commercial weight management organizations to be approved.
The [[Transtheoretical model|Transtheoretical Model]] (TTM) has been used as a framework to assist the design of lifestyle modification programmes, including weight management. A systematic review found that there is insufficient evidence to draw conclusions regarding the effects of TTM-based programs targeting weight loss that included dietary or [[physical activity]] interventions, or both (and also combined with other interventions), on sustainable [[weight loss]] (one year or longer) in [[overweight]] and obese adults. However, very low quality evidence points that this approach may induce positive changes in physical activity and dietary habits, such as increased in [[exercise]] duration and frequency, improvement in fruits and vegetables consumption, and reduced dietary fat intake.
</div>
<div lang="en" dir="ltr" class="mw-content-ltr">
==医薬品==
==Medication==
{{Anchor|Medication}}
{{Main|Anti-obesity medication}}
{{Main/ja|Anti-obesity medication/ja}}
[[File:Obesity Med2008.JPG|thumb|alt=The cardboard packaging of two medications used to treat obesity. Orlistat is shown above under the brand name Xenical in a white package with Roche branding. Sibutramine is below under the brand name Meridia. Orlistat is also available as Alli in the United Kingdom. The A of the Abbott Laboratories logo is on the bottom half of the package.|right|[[Orlistat]] (Xenical), the most commonly used medication to treat obesity and [[sibutramine]] (Meridia), a withdrawn medication due to cardiovascular side effects]]
* The [[combination drug]] [[phentermine/topiramate]] (Qsymia) is approved by the FDA as an addition to a reduced-calorie diet and exercise for chronic [[weight management]].
* Orlistat reduces intestinal fat absorption by inhibiting pancreatic [[lipase]]. Over the longer term, average weight loss on orlistat is 2.9kg. It leads to a reduced incidence of diabetes, and has some effect on [[cholesterol]]. However, there is little information on how it affects the longer-term complications or outcomes of obesity.
* The usefulness of certain drugs depends upon the comorbidities present. [[Metformin]] is preferred in overweight diabetics and for those gaining weight because taking [[clozapine]] for schizophrenia, as it may lead to mild weight loss in comparison to [[sulfonylurea]]s or [[insulin]]. The [[thiazolidinedione]]s, on the other hand, may cause weight gain, but decrease central obesity. Diabetics also achieve modest weight loss with [[fluoxetine]] and orlistat over 12–57 weeks.
* [[Rimonabant]] (Acomplia), another drug, had been withdrawn from the market. It worked via a specific blockade of the [[endocannabinoid]] system. It has been developed from the knowledge that [[Cannabis (drug)|cannabis]] smokers often experience hunger, which is often referred to as "the munchies". It had been approved in Europe for the treatment of obesity but has not received approval in the United States or Canada due to safety concerns. [[European Medicines Agency]] in October 2008 recommended the suspension of the sale of rimonabant as the risk seem to be greater than the benefits.
* [[Sibutramine]] (Meridia), which acts in the brain to inhibit deactivation of the [[neurotransmitter]]s, thereby decreasing appetite was withdrawn from the UK market in January 2010 and United States and Canadian markets in October 2010 due to cardiovascular concerns. In 2010 it was found that sibutramine increases the risk of [[heart attacks]] and [[strokes]] in people with a history of cardiovascular disease.
* [[Fenfluramine]] and [[dexfenfluramine]] were withdrawn from the market in 1997, while [[ephedrine]] (found in the traditional Chinese herbal medicine ''má huáng'' made from the ''[[Ephedra sinica]]'') was removed from the market in 2004.
* かつて[[Lorcaserin/ja|ロルカセリン]]は肥満症の治療薬として[[Food and Drug Administration/ja|食品医薬品局]]から承認されていたが、発癌の危険性があるとして承認が取り消された。
* [[Lorcaserin]] used to be approved by the [[Food and Drug Administration]] for use in the treatment of obesity before being withdrawn due to cancer risk.
* [[Recombinant DNA|Recombinant]] human [[leptin]] is very effective in those with obesity due to congenital complete leptin deficiency via decreasing energy intake and possibly increases energy expenditure. This condition is, however, rare and this treatment is not effective for inducing weight loss in the majority of people with obesity. It is being investigated to determine whether or not it helps with weight loss maintenance.
* Though hypothesized that supplementation of vitamin D may be an effective treatment for obesity, studies do not support this. There is also no strong evidence to recommend herbal medicines for weight loss.
Bariatric surgery ("weight loss surgery") is the use of surgical intervention in the treatment of obesity. As every operation may have complications, surgery is only recommended for severely obese people (BMI > 40) who have failed to lose weight following dietary modification and pharmacological treatment. Weight loss surgery relies on various principles: the two most common approaches are reducing the volume of the stomach (e.g. by [[adjustable gastric band]]ing and [[Vertical banded gastroplasty surgery|vertical banded gastroplasty]]), which produces an earlier sense of satiation, and reducing the length of bowel that comes into contact with food (e.g. by [[gastric bypass surgery]] or [[Duodenal-jejunal bypass liner|endoscopic duodenal-jejunal bypass surgery]]), which directly reduces absorption. Band surgery is reversible, while bowel shortening operations are not. Some procedures can be performed [[laparoscopic surgery|laparoscopically]]. Complications from weight loss surgery are frequent.
Surgery for severe obesity is associated with long-term weight loss and decreased overall mortality. One study found a weight loss of between 14% and 25% (depending on the type of procedure performed) at 10 years, and a 29% reduction in all cause mortality when compared to standard weight loss measures. A marked decrease in the risk of [[diabetes mellitus]], [[cardiovascular disease]] and [[cancer]] has also been found after bariatric surgery. Marked weight loss occurs during the first few months after surgery, and the loss is sustained in the long term. In one study there was an unexplained increase in deaths from accidents and suicide, but this did not outweigh the benefit in terms of disease prevention. When the two main techniques are compared, gastric bypass procedures are found to lead to 30% more weight loss than banding procedures one year after surgery. For obese individuals with [[non-alcoholic fatty liver disease|non-alcoholic fatty liver disease (NAFLD)]], bariatric surgery improves or cures the liver.
A preoperative diet such as [[calorie restriction|low-calorie diets]] or [[very-low-calorie diet]], is usually recommended to reduce liver volume by 16-20%, and preoperative weight loss is the only factor associated with postoperative weight loss. Preoperative weight loss can reduce operative time and hospital stay. although there is insufficient evidence whether preoperative weight loss may be beneficial to reduce long-term morbidity or complications. Weight loss and decreases in liver size may be independent from the amount of calorie restriction.
[[Ileojejunal bypass]], in which the digestive tract is rerouted to bypass the small intestine, was an experimental surgery designed as a remedy for morbid obesity.
The effects of [[liposuction]] on obesity are less well determined. Some small studies show benefits while others show none. A treatment involving the placement of an [[intragastric balloon]] via [[gastroscopy]] has shown promise. One type of balloon led to a weight loss of 5.7 BMI units over 6 months or 14.7kg. Regaining lost weight is common after removal, however, and 4.2% of people were intolerant of the device.
</div>
<div lang="en" dir="ltr" class="mw-content-ltr">
膨満感を改善する植え込み型神経シミュレーターが2015年にFDAに承認された。
An implantable nerve simulator which improves the feeling of fullness was approved by the FDA in 2015.
In 2016 the FDA approved an [[aspiration therapy]] device that siphons food from the stomach to the outside and decreases caloric intake.
</div>
<div lang="en" dir="ltr" class="mw-content-ltr">
== 健康政策 ==
== Health policy ==
{{Anchor|Health policy}}
Obesity is a complex public health and policy problem because of its prevalence, costs, and health effects. As such, managing it requires changes in the wider societal context and effort by communities, local authorities, and governments. Public health efforts seek to understand and correct the [[Obesity and the environment|environmental factors]] responsible for the increasing prevalence of obesity in the population. Solutions look at changing the factors that cause excess food energy consumption and inhibit physical activity. Efforts include federally reimbursed meal programs in schools, limiting direct [[Junk food|junk]] [[food marketing]] to children, The World Health Organization recommends the taxing of sugary drinks. When constructing urban environments, efforts have been made to increase access to parks and to develop pedestrian routes.
肥満は、その有病率、コスト、健康への影響から、複雑な公衆衛生および政策問題である。そのため、肥満の管理には、より広い社会的背景の変化と、地域社会、地方自治体、政府による取り組みが必要である。公衆衛生の努力は、人口における肥満の有病率増加の原因となっている[[Obesity and the environment/ja|環境要因]]を理解し、是正しようとするものである。解決策は、過剰な食物エネルギー消費を引き起こし、身体活動を阻害する要因を変えることにある。取り組みとしては、連邦政府から払い戻しのある学校での給食プログラム、子どもたちへの直接的な[[Junk food/ja|ジャンク]][[food marketing/ja|フード・マーケティング]]の制限などがある。世界保健機関（WHO）は、砂糖入り飲料への課税を推奨している。都市環境を構築する際には、公園へのアクセスを増やし、歩行者専用道路を整備する努力がなされている。
[[Mass media]] campaigns seem to have limited effectiveness in changing behaviors that influence obesity. At the same time they can increase knowledge and awareness regarding physical activity and diet, which might lead to changes in the long term. Campaigns might also be able to reduce the amount of time spent [[Sedentary lifestyle|sitting or lying down]] and positively affect the intention to be active physically. [[Nutrition facts label|Nutritional labelling]] with energy information on menus might be able to help reducing energy intake while dining in restaurants.
Since there is a relationship between obesity and automobile travel, interventions relating to transportation infrastructure (for example, policy aimed at encouraging the use of public transportation) could potentially reduce obesity.
</div>
<div lang="en" dir="ltr" class="mw-content-ltr">
== 臨床プロトコル ==
== Clinical protocols ==
{{Anchor|Clinical protocols}}
Much of the Western world has created [[clinical practice guidelines]] in an attempt to address rising rates of obesity. Australia, Canada, the European Union, and the United States have all published statements since 2004.
欧米諸国の多くは、肥満率の上昇に対処するため、[[clinical practice guidelines/ja|臨床診療ガイドライン]]を作成している。オーストラリア、カナダ、欧州連合（EU）、米国はいずれも2004年以降に声明を発表している。
</div>
<div lang="en" dir="ltr" class="mw-content-ltr">
[[:en:American College of Physicians|米国内科学会]]による臨床診療ガイドラインでは、以下の5つの勧告がなされている：
In a clinical practice guideline by the [[American College of Physicians]], the following five recommendations are made:
# People with a BMI of over 30 should be counseled on diet, exercise and other relevant behavioral interventions, and set a realistic goal for weight loss.
# If these goals are not achieved, pharmacotherapy can be offered. The person needs to be informed of the possibility of [[Adverse effect (medicine)|side-effects]] and the unavailability of long-term safety and efficacy data.
# Drug therapy may consist of [[sibutramine]], [[orlistat]], [[phentermine]], [[diethylpropion]], [[fluoxetine]], and [[bupropion]]. Evidence is not sufficient to recommend [[sertraline]], [[topiramate]], or [[zonisamide]].
# In people with a BMI over 40 who fail to achieve their weight loss goals (with or without medication) and who develop obesity-related complications, referral for [[bariatric surgery]] may be indicated. The person needs to be aware of the potential complications.
# これらの手術を頻繁に行う外科医は合併症が少ないというエビデンスがあるためである。
# Those requiring bariatric surgery should be referred to high-volume referral centers, as the evidence suggests that surgeons who frequently perform these procedures have fewer complications.
</div>
<div lang="en" dir="ltr" class="mw-content-ltr">
[[:en:US Preventive Services Task Force|米国予防医療タスクフォース]]（USPSTF）による[[clinical practice guideline/ja|臨床実践ガイドライン]]では、プライマリケア環境において非選択的な人々に[[healthy diet/ja|健康的な食事]]を促進するための日常的な行動カウンセリングを推奨する、または推奨しないことを推奨するにはエビデンスが不十分であるが、[[hyperlipidemia/ja|高脂血症]]や心血管疾患および食事に関連する慢性疾患のその他の既知の危険因子を有する人々には、集中的な行動的食事カウンセリングが推奨されると結論づけている。集中的なカウンセリングは、プライマリケアの臨床医が行うことも、栄養士や管理栄養士などの他の専門家に紹介することもできる。米国のプライマリケア医を対象とした調査によると、臨床ガイドラインでは過体重は死亡率を増加させる危険因子とはみなされていないが、医師はしばしば過体重であることが全死因死亡率を増加させると信じていると報告している。
A [[clinical practice guideline]] by the [[US Preventive Services Task Force]] (USPSTF) concluded that the evidence is insufficient to recommend for or against routine behavioral counseling to promote a [[healthy diet]] in unselected people in primary care settings, but that intensive behavioral dietary counseling is recommended in those with [[hyperlipidemia]] and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians. A survey of primary care physicians in the United States found that although clinical guidelines do not consider overweight to be a risk factor that increases mortality, physicians often report believing that being overweight increases all-cause mortality.
Canada developed and published evidence-based practice guidelines in 2006. The guidelines attempt to address the prevention and management of obesity at both the individual and population levels in both children and adults. The [[European Union]] published clinical practice guidelines in 2008 in an effort to address the rising rates of obesity in Europe. Australia came out with practice guidelines in 2004.
</div>
<div lang="en" dir="ltr" class="mw-content-ltr">
== 外部リンク ==
== External links ==
* {{Commons category-inline|Management of obesity}}
Media related to Management of obesity at Wikimedia Commons