Weight Management

Describe the epidemiology, health consequences, and risk factors associated with overweight and obesity, including metabolic syndrome and other obesity-related comorbidities

• Associated with:

  • CVD

  • DM type 2

  • Cancer

  • Orthopedic complications 

  • Many others

  • Reduced ADLs (Activities of Daily Living)

• Metabolic Syndrome: must have 3 of the following:

  • Waist circumference greater than 40 inches in men or 35 inches in women

  • Serum triglyceride levels of 150 mg/dL or greater

  • High-density lipoprotein (HDL) cholesterol less than 40 mg/dL in men or less than 50 mg/dL in women

  • Blood pressure level of 130 mm Hg systolic or 85 mm Hg diastolic or higher

  • Fasting serum glucose of 100 mg/dL or greater

• Medications that can increase obesity

  • Anticonvulsants

  • 2nd gen antipsychotics

  • TCAs, MAOIs, SSRIs

  • Systemic corticosteroids

  • Sulfonylureas, TZD, insulin

  • Hormonal contraceptives

Explain the pathophysiology of overweight and obesity, including the influence of various factors on weight regulation

• Pathophysiology

  • Genetics

    • Excess, deficiency, resistance to various hormones

      • Leptin, ghrelin, cortisol, PYY, cholecystokinin, GLP-1

    • Gut microbiome

      • Pre, pro, and synbiotics

  • Environment 

    • Increased portion sizes and caloric intake reflect trends over last several decades

    • Promoting genetic related triggers

      • Higher intake of sugar-sweetened products may promote those genetically pre-disposed to obesity to develop it

    • Decreased physical activity

    • Sleep disturbances/poor sleep

    • Medications

  • Energy expenditure process is complex

Assess and categorize overweight and obesity using appropriate tools and measurements, including calculating BMI

• Measure weight and height accurately

• BMI Scale

  • Underweight <18.5

  • Normal 18.5 - 25

  • Overweight 35-30

  • Obese >30

• How to calculate BMI

  • Kg/m^2 or ((lbs/in^2) x 703)

Identify when patients need to be referred and when they can self-treat

• Referral Criteria

  • Severe obesity (BMI 40 or greater)

  • Pregnancy or breastfeeding

  • <18 or >65 years old

  • Cardiovascular disease, dyslipidemia, diabetes, hypertension

    • Caution with stimulants in OTC medications

    • Caution with blood glucose fluctuations

  • Eating disorders

Identify and compare/contrast nonpharmacologic and pharmacological strategies for weight management, including diet/exercise recommendations and the use of Orlistat (dose/usage, ADRs, DDIs, and counseling information)

• Nonpharmacologic strategies

• Dietary Intervention

  • Deficit of 500 kcal/day to lose 1 lb/week

  • 3500 kcal deficit for 1 lb loss/week

  • Healthy weight loss is 1-2 lb/week for most people

  • Low calorie diet (LCD) → 1200-1800 kcal/day

  • Very low calorie diet (VLCD) → 800 or fewer calories /day

    • Only under medical supervision

    • Usually liquid formulations given several times a day

    • Double the weight loss than LCD after 12-16 week but long term results are the same

    • Multivitamin and multimineral recommended if consuming

  • Intermittent fasting results in similar weight loss and metabolic improvements

  • Daily caloric allowances for moderately active individuals vary with age, gender, and body weight

    • Older persons need lower caloric intake

    • Younger adults need higher caloric intake

    • Caloric requirements for women increase during pregnancy and lactation

• Commercial Weight Loss Programs

  • All work with similar plan

    • Meal plan

    • Portion control

    • Caloric restriction

    • Social support

    • Online tools

    • GLP-1, GLP-1/GIP agonists

  • Success often attributed to social support, online tools, medications

• Meal Replacement Therapy

  • Replace up to two meals a day with liquid drink, snack bar, or measured frozen meal

  • Products typically contain 200-300 kcal/serving

  • Usually low fat, sometimes low carb

  • Encourages portion control

  • Initial weight loss partially due to low sodium content of foods

• FAD Diets (do not recommend)

  • Concerns about long term safety 

    • Lack of essential nutrients

    • High protein → build up of uric acid = gout

      • Bad for bone health

    • Restriction of fruits, veggies, whole grains, and milk → increase cancer risk

    • ex) Atkins, Zone

• Physical Activity

  • Children/adolescents

    • ≥ 60 min of moderate or vigorous aerobic activity per day

    • Vigorous activity at least 3 days per week

    • Muscle strengthening activities at least 3 days per week

  • Adults

    • 150-300min of moderate aerobic activity OR

    • 75-150min of vigorous activity per week

    • ≥10min intervals Muscle strengthening activities at least 2 days per week

• Pharmacological Strategies

• Generally NOT recommended for weight loss

• Orilistat: Rx and OTC dual status medication

  • Rx: 120mg TID for ages 12 and up (Xenical) 

  • OTC: 60mg up to TID for ages 18 and up (Alli)

    • Used alongside diet and exercise

  • MOA: reduces absorption of dietary fats by inhibiting lipase

  • ADR:

    • Oily spotting, loose/frequent stools, fatty stools, fecal urgency

    • Reduced absorption of fat-soluble vitamins 

  • Counseling

    • Must take MVI (multivitamins)

    • Limit fat intake to 15g per meal to help GI ADRs

    • Discontinue when patient BMI reaches 25 or less

  • Drug interactions:

    • Besides Vitamin K dependent anticoagulants (increased risk of blood coagulation), every other drug has REDUCED concentrations of absorption

• Natural Products and Supplements

• OTC laxative abuse:

  • Can lead to severe electrolyte imbalance

  • Dehydration

  • Kidney damage 

  • Cardiac arrhythmias

  • Death

Given a patient case, recommend pharmacologic and nonpharmacologic therapies for weight management

• RECOMMENDATIONS (general)

  • Initial goal: 5-10% over 6 months for weight loss

    • Rate of 1-2 pounds/week

  • USPSTF recommends that clinicians screen:

    • Children aged 6 years and older for obesity

    • ALL adults for obesity

    • Clinicians should offer or refer pt to comprehensive, intensive behavioral intervention to promote improvement in weight status