weight management exam 3

pregnancy expected weight gain

• normal: 25-25 lbs

• overweight: 15-25 lbs

• obese: 11-20 lbs

kids weight gain considerations

• children still have vertical growth that we must consider

• sometimes weight loss is medically necessary for children IF it needs to be done for weight loss

children obesity trend into adulthood

• children with obesity often become a teen with obesity

• goal should be to stabilize weight

plan for overweight children

• focus on activity

  • frame as movement with children

• basic nutrition improvement

  • parents need to consider what food they buy

  • keep having children try food - a child needs to try a food 8-10 times in order to like it

• parents MUST be on board and model the correct behavior

what should a parent consider

• portion sizes (a child’s first is much smaller than an adult - how you consider carb portion)

• must set an example

• where is the family eating (in front of TV, the couch?)

• talk with childcare

• offer a variety of food textures, shapes, temperatures

• have kids take ownership (have them help cook, grocery shop, etc)

• parents should avoid dieting and need to watch what they say

• do NOT put kids on a diet

what does contraindications for weight loss

• points where someone should not be losing weight

examples of contraindications for weight loss

• uncontrolled and untreated psychiatric illness

• anxiety disorders

• clinical depression (25-30% of people have symptoms of depression)

• bulimia nervosa

• binge eating disorder (greater than 25% of obese adults have symptoms)

• anorexia nervosa

• substance abuse

signs of disordered eating patterns

• eating more rapidly than normal

• consuming large amounts of food when not hungry

• eating alone because of embarrassment

• feeling guilty after eating

• reports of purposefully starving yourself throughout the day and bingeing at night

• history of an eating disorder

orthorexia

• attempts to eat really “clean” → restrict lots of food, some foods are not “safe”

  • “safe” foods cause no guilt after eating them

• begins in an attempt to eat healthier

• appears innocent at first

• problem: self-worth is tied to a food choice

what is orthorexia associated with

• often leads to anorexia nervosa

  • big clue is loss of mensuration

how is anorexia nervosa defined

• low body weight

  • BMI is lower that 18.5 for adults and a weight in the 5th percentile for children

• must have an intense FEAR of becoming fat

• behaviors interfere with weight restoration

• nervosa: body image distortion, obsessive thoughts, fear of weight gain

AN influences

• body image distortion has a big influence on body weight and their self-worth

• don’t recognize the severity of low BW

  • don’t believe there is anything wrong with them weight 90lbs

• associated with OCD and a perfectionist personality

what do people with AN do

• restriction of energy intake/calories

  • may restrict heavily then purge or complete intense exercise

• compulsive exercising

  • disordered relationship with exercise

  • feel like they need to exercise in order to eat

AN clinical sign

• thinning/loss of hair

• mental health conditions (anxiety, depression, etc)

• loss of period + decrease of hormones

• loss of bone and muscle mass (osteopenia/osteoporosis)

• GI symptoms (constipation, GRED, etc)

• low HR, low BP

AN death stat

• the second highest proportion of mental illness-related death (often stems from organ failure as a result of malnutrition or suicide)

atypical anorexia nervosa

• all the same symptoms as AN BUT does NOT meet BMI

  • often will appear as a normal weight or even overweight

• hard to diagnose and is often missed

  • no DSM-5 criteria

  • people often think since they aren’t skinny, they aren’t restricting

prevalence of AN vs AAN

• in woman of 20 years old

• AAN is 2.8%

• AN is 0.8%

major barrier to treating eating disorders in people who are normal weight/overweight

• weight bias

what is bulimia nervosa/criteria

• recurrent episodes of binge eating followed by a PURGE of some time

• eating an amount of food that is definitely larger than most people would eat in a similar period of time

• have a sense of lack of control during the eating episode

  • feel like once they start eating, they CANNOT stop

what people with bulimia nervosa often do

• have recurrent compensatory behaviors to prevent weight gain

  • vomiting, laxative, excessive exercise

• bingeing and purging must occur at least ONCE a week for 3 months

• self-evaluation of their body heavily influence by their weight and shape

binge eating disorder

• recurrent episodes of binge eating

BED vs. Bulimia Nervosa

• Bulimia Nervosa MUST have a method of purging after the binge whereas BED DOES NOT

what is BED episodes associated with

• MUST have 3 or MORE of the following

  • eating more rapidly than normal

  • eating until uncomfortably full

  • eating large amounts of food when not physically hungry

  • eating alone due to embarrassment about how much one eats

  • feeling disgusted with oneself, guilty, depressed after eating

• CAN be premeditated

• BMI can be ANYTHING

how do ED and obesity fit - stats

• EDs are the THIRD most common chronic condition for teens

  • obesity is first and asthma is second

• from 1999-2006, hospitalizations for EDs increased 119% for children younger than 12 yrs old

• increase in AN in teenage girls ages 15-19

  • due to vulnerable time of puberty

• people often DO NOT start obese

  • start with eating health/orthorexia and then can lead to obesity

fine line of trying to get society to eat healthy

• need to ensure that obesity prevention DOES NOT lead to development of EDs in society

obesity and ED correlation

• misinterpreting the message of “eating healthy” to restricting/avoiding foods

  • think of our conversation of labeling food

• dieting

  • calorie restriction of a goal of weight loss

    • leads to ED

    • kids start to get the message that too many calories are bad

    • often hear about restriction/calorie limiting from parents

• family meals

  • more family meals is associated with fewer EDs and obesity

  • parents modeling behavior, more family interactions, monitor eating behaviors, higher quality meals, better portion control management

• weight talk

  • comments made about weight/size of yourself OR a child

  • typically affects females with belief that smaller is better

• weight teasing

  • 40% of overweight teens experience this by family or peers

• healthy body image

  • ½ of teens and ¼ of boys are dissatisfied with their bodies

  • higher in overweight teen

obesity proper prevention and treatment

• strengthen personal motivation

  • what does a kids want

• commitment to a very specific goal

• lifestyle behavior changes

health definition according to WHO

• state of complete physical, mental, and social-wellbeing and not merely the absence of disease or infirmity

oblivobesity

• term used to describe the tendency to overlook obesity, usually due to parent’s lack of awareness of their child’s weight status

unawareness vs misperception

• unawareness: recognizes no harm

• misconception: denies harm

body figure article takeaways

• leading causes of mortality in the US are attributed to excess fat (lung, kidney, heart disease)

• people carry weight differently

• 70% of female adolescents who perceive themselves as overweight are using weight management strategies

• number of weight loss attempts increases with body size

• body image/dissatisfaction may appear as early as second grade

• girls/woman often perceive their current body weight as heavier

body image definition

• a person’s perception of their physical self and the thoughts, feelings, positive, negative, or both, that results from that perception

• includes:

  • perceptual body image - how they see their body

  • affective body image - how they feel about their body

  • cognitive body image - how they think about their body

  • behavioral body image - how they react as a result of their body image

what type of body image is most related to body figure perception

perceptual

what body image/s are most related to how people response in regard to perception in feelings and thoughts

affective and cognitive

what body image best relates how individuals physically react to perceptions, thoughts, and feelings of their body image

behavioral

weight perception girls vs boys

• girls are more satisfied with thinner bodies

• boys have a stronger desire to increase weight and develop lean body mass

weight cycling definition

• repeated cycles of intentional weight loss and unintentional regain

• common

• referred to as “yo-yo” dieting

• characterized by the metabolic adaptation to weight loss

weight cycling statistics

• estimated 80% of individuals who intentionally lost more than 10% of their body weight will regain that weight within a year

why does weight cycling occur

• food environment

• weight overshooting

• adaptive thermogenesis

• adaptive response to food supple

what is weight overshooting

• weight loss reduces fat and lean body mass

• metabolic shifts that favor fat storage occur

• fat overshooting is when fat regain exceeds the amount of fat lost is NECESSARY to allow complete recovery of lean mass during weigh regain

what is adaptive thermogenesis

• thermogenesis (burning of calories to produce heat) declines with weight loss

• stays depressed during weight regain

• associated with an increased drive to eat

what is adaptive response to the food supply

• recurrent attempts to diet/lose weight will lead the body to have greater fat storage than if an individual was never restricting food

• due to biological response that our ancestors had in times of survival

how does weight cycling affect the body

• dieting is a predictor of future weight gain

• the more frequent the weight cycling, the greater the increase in BMI and risk of becoming overweight

• the lower the dieter’s initial body fat percentage = higher proportion of lean mass lost = higher proportion of fat mass gained

• lean dieters are at a greater risk for overshooting than overweight/obese dieters

• weight cycling is MORE associated with disease risk

when were the first weight loss drugs made and what were they

• the 1950s/1960s

• amphetamines (stimulants)

  • these typically suppress appetite

pathway of managing weight loss

• first address diet and lifestyle modification

• then try pharmacotherapy (drugs)

• LAST option is surgery

NIH guidelines for weight loss drugs

• need to be high-risk patients

  • BMI greater than 30 OR greater than 27 with 1 or more comorbidities

• FDA approval for long-term use

• used ONLY in conjunction with diet, PA, and behavioral therapy

• initiate ONLY when diet and lifestyle modifications fail after 6 months

who should take weight loss medication

• must meet the BMI guidelines and NIH guidelines

• pts who have the inability to lose weight when modifications have already been made

• pts who need to have surgery where immediate weight loss to undergo procedure is required

• MUST be ready to make changes to their lifestyle along with being on the medication

weight loss drugs

• NOT all patients response equally to the meds

• do NOT work for everyone

• if patient is unable to lose 2kg (~5lbs) after 4 weeks, the medication is considered to not work

FDA considerations for approval for long term use

• 2-year safety and efficacy data on the drug

• does the drug have a potential to be abused

  • is it an addictive substance

• MUST result in 5-10% MORE weight loss than with a strong diet/PA alone

• must help MAINTAIN weight loss

• potential to reduce the comorbidities

how do weight loss drugs work

• decrease food/energy intake

  • suppress the appetite

  • increase fullness quicker

  • increases feeling of reward quicker

• decreases fat absorption through the GI tract (excreted in urine and less caloric/nutrient absorption)

• reduces body fat by stimulating energy expenditure

  • found that peripheral norepinephrine may increase energy expenditure

drug that works as appetite suppressant and affects satiety

• phentermine

  • decreases appetite and makes you feel full longer

  • approved for 12-weeks but MDs can prescribe longer

• combined with topiramate for Qsymia

  • topiramate: anti-seizure med but used off-label for weight loss

  • BUT can be habit forming (addictive)

  • many side effects

• MUST be used in combination of calorie reduction and increased PA to be effective

• follow up with patient MUST occur

drug to reduce fat absorption

• Orlistate (Xenical)- Rx version is 120mg dose

• OR Alli - OTC version at 60mg dose

• long-term use

• blocks absorption of ~30% of dietary fat from small intestine and works as a lipase inhibitor

• need to supplment fat-soluble drugs - AEDK

• weight loss is not as significant as other meds

• need to take 3 times daily

adverse side effects of Orlistat

• smelly farts

• steatorrhea - white mucus in poop

• stool leakage - poop your pants

why was Alli created

• to decrease the bad side effects of Orlistat

• fewer GI events

• BUT lower weight loss results

• lower withdrawal rate

off-label diabetes medications for weight loss

• Metformin (glucophage)

• Pramlintide (symlin)

• Exenatide (byetta) and Liraglutide (victoza)

Metformin

• diabetes med used off-label for weight loss

• reduces glucose absorption and glucose production in liver

• studies show around 2% BW reduction

• helps a lot of PCOS patients

• helps woman ovulate regularly and those who have metabolic syndrome

Pramlintide

• diabetes medication sued off-label for weight management

• promotes satiety

Exenatide and Liraglutide

• diabetes medication used off-label for weight management

• reduces food intake with GI peptide release

• 5-10% body weight loss

Wellbutrin

• diabetes medication used off-label for weight management

• main use is for an anti-depressant

how do diabetes/weight loss injectables function

• glucagonlike peptide-1 (GLP-1) receptor agonist

• glucose-dependent insulinotropic polypeptide (GIP) combined with GLP-1

• demonstrated 15% weight loss in people with obesity and/or DMS

best candidates or weight loss injectables

• overweight AND 1 comorbidity: DM2, sleep apnea, CVD, chronic renal disease

GLP-1 receptor agonists

• increase satiety, decrease appetite

• glucagonlike peptide 1

  • slows gastric emptying

  • decreases post-prandial (post-meal) glucose levels

  • stimulates pancreatic beta cells to release insulin and decrease glucagon secretion

GIP

• receptors found in adipose tissue

• glucose-dependent insulinotropic polypeptide

  • increases insulin secretion and decreases glucagon secretion

what do the injectables target/what do they prove in weight loss

• target the incretin system

  • system that releases hormones in the GI tract in response to food

  • drugs stimulate insulin, suppress glucagon, and increase satiety

• show MOST effectiveness in WL in those with extra fat but NOT as much as an effect in weight loss of pts with DM2

• extra fat → leads to altered function of GIP, GLP-1, insulin, and glucagon

  • meds help to regulate to “normal” function

what to consider with weight loss injectables

• must be taken at same time every day/week

• insurance coverage/costs

• side effects

• drug interferences

• risk of hypoglycemia (low blood sugar)

• follow your correct dosing

• “Ozempic face” - loss of facial fat - gaunt look in face due to rapid weight loss

contraindications to using weight loss drugs

• pregnant/breastfeeding

• history of gastroparesis (delayed stomach emptying)

• family history of thyroid carcinoma, multiple endocrine neoplasm syndrome type 2

• fear of needles

• patient is noncompliant

• coverage concerns

side effects of weight loss injections

• nausea, vomiting, constipation, diarrhea

• GI complications

  • gallbladder concerns

  • gastroparesis

• nutrient inadequacies

• muscle and bone loss

what do people need to do while on weight loss medications

• maintain lean muscle tissue

  • strength train

  • meet your protein needs (often difficult due to decrease appetite)

• engage in healthful lifestyle changes

  • consider psychological, environmental health, stress, biological issues

• long-term medication might be needed

• benefits include other chronic disease management and decreased risk (CVD, DM2, HTN)

Wegovy

• (semaglutide) injection (2.4mg once weekly)

  • progresses in does over 16-20 weeks (help reduce the GI side effects)

  • mimics glucagonlike peptide-1 (GLP-1)

  • targets area of brain responsible for appetite control and food take

• Conditions o use/; energy intake restriction AND increased PA

• uses:

  • chronic wt management for BMI greater than 27 with 1 chronic disease

  • OR

  • BMI greater than 30

Ozempic

• NOT a weight loss drug - used off label

• uses:

  • with diet and PA improves blood sugar levels in adults with DM2

  • to reduce risk of cardiovascular events like MI, stroke, death

• works:

  • contains active ingredient that lowers blood sugar levels by helping pancreas produce MORE insulin - liver is restricted from releasing too much sugar - slows the rate of food traveling though digestive system

  • regulates hunger/fullness cues

GLP-1 pills

• Wegovy Pill

  • 1st on market, FDA approved Dec 2025

  • once daily, increase dose to 25mg

  • must be taken same time of day in AM on empty stomach

• Foundayo

  • FDA approved in March 2026

  • taken anytime without food or water

• both trials show 12-17% BW loss over 72 weeks (1 yr)

• cheaper than injectable

weight management tricks that work like a med

• diet

  • high protein

  • high fiver

  • adequate healthy fats

• this combo:

  • reduces hunger and appetite

  • slow down digestion and nutrient absorption

• BUT only last a few hours where a med lasts MUCH longer

bottom line of WL drugs

• can help reduce “foo noise” and hunger feelings

• no best medication - work differently in each person

• pts need to still address food choices when on meds

• combined drug therapy with PA and healthful eating is most beneficial

• most people lose 5-10% BW during drug therapy

• some weight gain is expected

• lifestyle intervention MUST occur

estimated number of Americans who undergo Bariatric surgery annually

weight loss surgery

• procedures that impact the physiological regulation of body weight and improve morbidity (rate of disease) and mortality rates

candidates for WL surgery

• BMI greater than 40 OR BMI greater than 35 with comorbidity linked with obesity

• diet and PA measures failed

• drugs failed

• must have undergone physiological, nutrition, and medical screening

what does Bill say about WL surgery

• surgery is a TOOL

• it is NOT a cure

diet-considerations pre-op

• need to shrink the liver (it is usually large in obese patients and that leads to possible complication of nicking the liver during surgery)

pre-op diet

• low carb, high protein

• allow for 30-45 minutes to eat meal (slowly eating allows for release of CCK hormone)

• small bites of food

• start MVI (multiple vitamins intravenous) with Fe

• avoid sugar-based drinks/carbonation

• fluids should be close to 64oz a day

two methods of WL surgery

• gastric restriction (decrease stomach size)

• intestinal malabsorption of nutrients (bypass parts of the small intestine)

two methods of gastric restriction

• laparoscopic adjustable gastric band (LAGB)

• sleeve gastrectomy

• wt loss is not as dramatic or sustainable, BUT fewer complications

laparoscopic adjustable gastric band (LAGB)

• FDA approved for those of BMI greater than 30 with 1 comorbidity

• promotes early fullness

• size of “stomach” or gastric pouch is adjustable with saline injections that will inflate/deflate the restriciton

• malabsorption not typically an issue - nutrients absorbed as normal

LAGB advantages

• shorter hospital stay

• reversible/adjustable

• lowest rate of postoperative complications/mortality

• low risk for vitamin/mineral deficiencies

• reduces amount of food stomach can hold

• induces excess weight loss of ~40-50%

• NO cutting of stomach/rerouting of intestines