Healthy weight APT Exam 3

Anthropometric Measurements

• Height/length (limb length)

• Weight

• Head circumference (under 3 yrs)

• Waist circumference

• Ratios (waist:hip or waist:height)

Healthy weight tools definition

comparison of measurements to normalized population data

Limitations to weight tools?

• Hydration status (changes mass)

• Time of day

• Lean mass vs total mass

Growth measurement for children 0-2 years old

• WHO growth chart

  • sex specific

  • Weight for length

  • head circumference for age

  • Length for age

  • Weight for age

  • Normed for breastfed infants

• Percentile tracking

Growth measurement for children 2-19 years old

• CDC growth chart

  • Sex specific

  • Stature, weight and BMI for age

  • weight for stature

  • Normed for US children (cultural differences)

• Percentile tracking

Growth measurement for adults

• BMI (weight(kg)/height (m2))

• Racial/age differences (country specific)

• Body composition and CV risk

What are the 2 types of Meal replacement products:

• Shakes (premade or powders)

• Bars

Differences between meal replacement and protein supplement

• Legal definition

• Composition

Meal replacement MOA:

• Weight loss: control caloric intake

• Supplement: add nutrients into dietary intake

• Weight gain: add calories/nutrients into diet

Meal replacement self-care exclusions:

• Organ dysfunction

• GI dysfunction

• Significant unintended weight loss

• Concomitant disease affected by diet (diabetes, gastroparesis, cancer)

• Formula given as tube feed

When might self-care with meal replacement be OK in some cases?

If pt exclusion factor is controlled and been evaluated by a provider

When to use meal replacement:

• Alternative to 1 meal per day

• Supplement nutrients by ADDING to diet

Recommended servings of a meal replacement can be given when SUPPLEMENTING (added nutrients)

½ - 1 serving in between meals (up to 2 per day)

What needs to be evaluated before choosing a meal replacement?

• Caloric needs

• Macronutrient needs

• Micronutrient needs

• Ingredients (Allergens)

How long to use a meal supplement/replacement for?

Based on indication

• Weight loss/gain: If results in 4-6 weeks, can continue or if not then discontinue

• Supplement: If health is stable, continue as needed

Weight based lifestyle changes to monitor:

• Portion (measure servings)

• Track intake

• Track exercise

• Weigh self at same time once weekly

“HAND“ portion sizes

• cupped hand: snacks (1/2 cup nuts/fruit)

• palm: protein (100g)

• fist: carbs (1 cup rice, fruit or veggie)

• two handful: salads

• thumb: dairy (about 2 tbsp cheese or peanut butter)

• fingertip: fats (1 tsp oils, butter, mayo)

Average caloric intake for US adult

1500-2000 kcal per day

Do not decrease daily caloric intake under _____ kcal without medical supervision

1200

Low carbohydrate diet:

• Atkins

• Zone

Low fat diet:

Ornish

High protein diet: (caution in CKD)

Paleo

High fat diet: (caution in gallbladder disease)

Keto

What is the recommended weekly exercise that contributes to weight loss/maintenance?

150 mins per week

What hormones are responsible for fat storage and how can we manage them?

• Hormones: Cortisol and Estrogen

• Manage: Sleep and lower stress (meditation, relaxation, cognitive behavioral therapy)

What types of behavioral health effect weight and how to manage:

• Behaviors: Binge eating or fasting

• Manage: Cognitive behavioral therapy

Best outcomes with weight loss/gain/maintenance:

SMALL lifestyle changes over time (large changes are difficult to maintain)

OTC weight loss products:

orlistat (Alli)

Orlistat (Alli) MOA:

Inhibits intestinal lipase making dietary triglycerides unable to be hydrolyzed into absorbable fatty acidsA

Adverse effects of Orlistat (Alli):

• Abdominal discomfort/pain (41%)

• Defecation urgency (1st year 39%, 2nd year 2.8%)

• Flatulence (1st year 44%, 2nd year 2.1%)

• Oily discharge

Orlistat (Alli) dosing:

60 mg TID with each fat containing meal (within 1 hour)

Orlistat (RX and OTC) counseling points:

• Take with nutritionally balanced diet

• Take with daily multivitamins with A, D, E,K and B-carotene TWO hours apart from medication (this makes it hard to maintain)

Regulatory requirements of weight loss supplements:

• Trials must include wide range of BMI

• 5% or greater weight change compared to placebo

• Proportion of 5% or greater weight los is 35% or greater of study population

Prescription weight loss medications:

• Orlistat (Xenical)

• Phentermine

• Topiramate

• Phen/Topir (Qsymia)

• Naltre/Bupro (CONTRAVE)

• GLP-1 Agonists

RX strength Orlistat (Xenical) dosing:

120 mg TID with each fat containing meal (within 1 hour)

Orlistat (Xenical) risks as opposed to OTC Alli:

Higher risk of side effects*

Phentermine MOA:

Sympathomimetic amine similar to amphetamine, exact mechanism unknown

Phentermine ADRs:

• CNS stimulation (anxiety or insomnia)

• Xerostomia

Topiramate MOA:

Suppresses appetite, increases satiety (exact M unknown)

Topiramate ADRs:

• Dizziness

• Impaired cognition

Phentermine/Topiramate (Qsymia) Dosing

TITRATION

• 3.75mg/23mg QD x14 THEN 7.5mg/46mg D (discontinue or escalate if loss on achieved at 12 weeks)

• MAX: 15mg/92mg (discontinue if 5% loss not achieved in 12 weeks)

• Discontinuation: gradual taper, one dose QOD x1W (if abrupt = seizures)

Naltrexone/Bupropion (CONTRAVE) MOA:

Regulate dietary intake by increasing neuronal firing rate in reward system of brain (reduce cravings)

Naltrexone/Bupropion (CONTRAVE) ADRs:

• Constipation (19)

• Nausea (33)

• Depression (7)

• Anxiety (4)

• Dizziness (10)

• Headache (18)

• Insomnia (9)

Naltrexone/Bupropion (CONTRAVE) Dosing:

• 8mg/90mg QAM x1W

• 1BID x1W

• 2QAM and 1QPM x1W

• 2BID

(discontinue if 5% loss not seen after 12 weeks- relies on person to eat less due to reward center block)

GLP-1 Agonist MOA:

Delay gastric emptying (increase satiety) which causes decreased intake

GLP-1 Agonist ADRs:

• Constipation

• Nausea

• Rare: thyroid/breast/pancreatic cancer or pancreatitis

GLP-1 Agonists currently approved for weight loss

• Semaglutide (wegovy) (2.4+ or 25mgPO)

• Tirzepatide (Zepbound) (max 15mg)

• Liraglutide (Saxenda) (3mg)

RX weight loss meds removed from market:

• Fen-phen (heart disease and HTN)

• Meridia (increase MI and stroke risk)

• Belviq (increased risk of cancer)

What drug interactions need to be considered with weight loss meds?

• MAOIs

• Opioids

• Fat soluble vitamins

• HTN meds

• Diabetes meds

Naltrexone-bupropion contraindication with MAOIs:

• Monoamine oxidase inhibitors work on serotonin system to treat depression (irreversible inhibitors increase serotonin levels)

• May result in serotonin syndrome

• Discontinue MAOIs atleast 14 days before meds that increase serotonin (N/B aka contrave)

Naltrexone-bupropion contraindication with Opioids:

• Naltrexone is an opioid antagonist and can precipitate opioid withdrawal

• Discontinue opioids (short acting 7-10) (long acting 14) days prior to contrive

Opioids may worsen side effects (constipation) for which other drugs?

• GLP-1 agonists

• Topiramate (potential)

Why supplement fat soluble vitamins when taking orlistat?

absorption of them is blocked/decreased

HTN meds are contraindicated in weight loss meds that…

• Stimulants and Diuretics

• Weight loss meds may increase HR, BP and fluid status

How do we as pharmacists manage drug interactions?

• Complete medication history

• Screen for drug interaction at every visit

• For chronic disease: keep food intake log, work with dietitian, ensure baseline health appropriate for weight loss