Obesity

obesity

a chronic condition characterized by an excess of body fat

- most often defined by the BMI

BMI = [wt (lbs)/ht (in)^2]*703

BMI calculation

<5th percentile

underweight BMI is <18.5 kg/m^2. what percentile in children corresponds with this BMI?

5th-84th percentile

normal BMI is 18.5-24.9 kg/m^2. what percentile in children corresponds with this BMI?

85th-94th percentile

overweight BMI is 25-29.9 kg/m^2. what percentile in children corresponds with this BMI?

≥95th percentile

obesity class 1 BMI is 30-34.9 kg/m^2. what percentile in children corresponds with this BMI?

BMI ≥ 120% of the 95th percentile or a BMI ≥35

obesity class 2 BMI is 35-39.9 kg/m^2. what percentile in children corresponds with this BMI?

BMI ≥ 140% of the 95th percentile or a BMI ≥40

extreme obesity (class 3) BMI is ≥40 kg/m^2. what percentile in children corresponds with this BMI?

Cushing syndrome

Leptin deficiency

Growth hormone deficiency

Insulinoma

Depression

Binge eating disorder

Schizophrenia

list some medical conditions that cause weight gain

Clozapine (Clozaril)

Olanzapine (Zyprexa)

Risperidone (Risperdal)

Quetiapine (Seroquel)

Chlorpromazine (Thorazine)

list the atypical antipsychotics that cause weight gain.

Amitriptyline (Elavil)

Nortriptyline (Pamelor)

Mirtazapine (Remeron)

Paroxetine (Paxil)

list the antidepressants that cause weight gain

Valproic acid (Depakene)

Divalproex (Depakote)

Gabapentin (Neurontin)

Pregabalin (Lyrica)

Carbamazepine (Tegretol)

list the antiepileptics that cause weight gain

Insulin

Sulfonylureas

Pioglitazone (Actos)

list the diabetes medications that can cause weight gain

Propranolol (Inderal)

Metoprolol (Lopressor, Toprol XL)

Doxazosin (Cardura)

Terazosin (Hytrin)

list the antihypertensives that can cause weight gain

Medroxyprogesterone (DepoProvera)

COCs

Conjugated estrogens: Premarin

list the hormonal agents that can cause weight gain

Leptin

Insulin

GLP-1

list the hormones that work on the arcuate nucleus of the hypothalamus to decrease eating

Norepinephrine alpha-1

5-HT2c

list the neurotransmitters that work on the hypothalamus to decrease eating

ghrelin

what is the hormone that works on the vagus nerve to increase eating?

1-2 pound weight loss/week

Low caloric intake is intended to produce an energy deficit of 500-750 kcal/day, which generally leads to a _____ pound weight loss per week.

1200-1500 kcal/day

low caloric intake for women?

- should produce 1-2 pound weight loss/week

1500-1800 kcal/day

low caloric intake for men?

- should produce 1-2 pound weight loss/week

Mediterranean

which diet is described below?

- Focus: Whole, minimally processed foods

- Emphasizes: Fruits, vegetables, whole grains, legumes, nuts, olive oil, fish

- Minimizes: Red meat, processed foods, saturated fat

- Benefits: Heart-healthy, associated with reduced cardiovascular risk, improved insulin sensitivity, and modest weight loss

Weight Watchers

which diet is described below?

- Structure: Commercial program using a points system to guide food choices

- Encourages low-calorie, nutrient-dense foods

Includes behavioral strategies, group support, and tracking tools

- Flexible and customizable

- Evidence supports its modest effectiveness in weight loss

LEARN

which diet is described below?

- Acronym: Lifestyle, Exercise, Attitudes, Relationships, Nutrition

- Behavior-focused program combining dietary change with psychological and social strategies

- Promotes balanced diet, physical activity, and cognitive-behavioral therapy (CBT) principles

- Supported by clinical evidence as an effective structured weight-loss intervention

Jenny Craig

which diet is described below?

- Structure: Commercial weight-loss program

- Provides prepackaged meals, snacks, and menus

- Offers one-on-one coaching

- Simplifies calorie control but may be less sustainable long-term if patients do not learn to cook or make choices independently

- Evidence supports modest weight loss

Ornish

which diet is described below?

- Low-fat vegetarian diet: Extremely low in fat (~10% of calories), no animal products (except nonfat dairy/yogurt optionally)

- Emphasizes: Fruits, vegetables, whole grains, legumes

- Includes stress reduction, exercise, and group support

- Shown to reverse coronary artery disease, but long-term adherence can be difficult

Zone

which diet is described below?

- Balances macronutrients in a 40% carbs / 30% protein / 30% fat ratio

- Focuses on controlling insulin levels and inflammation

- Includes lean meats, fruits, vegetables, low-glycemic carbs

- Weight loss is modest, and evidence is mixed; more complex to follow

Atkins

which diet is described below?

- Low-carbohydrate, high-fat, high-protein diet

- Structured in phases: Initial strict carb restriction (<20g/day)

then gradual carb reintroduction

- Promotes rapid early weight loss

- Can improve blood sugar and triglycerides, but long-term safety and adherence remain concerns

Noom

which diet is described below?

- App-based program focusing on behavioral change

- Uses psychology and self-monitoring tools (color-coded food system, coaching, CBT)

- Encourages calorie deficit through informed food choices, without strict food rules

- Supported by early evidence as an effective digital intervention for sustained weight loss

150 min/week

- start 10 min of physical activity 3 days/week then titrate up to 30 min a day until the goal 150 min/week is reached

what amount of physical activity is recommended?

bariatric surgery

- Roux-en-Y gastric bypass

- Sleeve gastrectomy

- Adjustable gastric banding

- Biliopancreatic diversion with duodenal switch

most effective and durable intervention; reserved for extreme obesity BMI ≥ 40, BMI ≥ 35 with significant comorbidities (T2DM, HTN, Dyslipidemia, NAFLD, obstructive sleep apnea), or BMI 30-34.9 if diabetes or metabolic syndrome is not adequately controlled

wound infection

bleeding

DVT/PE

micronutrient deficiency: vitamin B12

decreased absorption of fat-soluble vitamins

anemia

risks associated with bariatric surgery

Maestro rechargeable system

electrical stimulation system that delivers 12-15 h of intermittenet nerve block to increase satiety

- indicated for: BMI 40-45 or BMI 35-39.9 with at least one comorbidity who have failed weight management treatment in the last 5 years

- battery must be charged for at least 30 min a day

- TBWL: 9.2% after 1 year

- AEs: abdominal pain, heartburn, dyspepsia, site pain

Orbera Intragastric Balloon

gastric balloon system that occupies stomach space to induce satiety

- indicated for: BMI 30-40 or 27-50 with failure of diet/exercise with comorbidities

- TBWL after 1 year of therapy is 11.3%.

- must be removed in 6-12 months due to risk of obstruction from deflation

- use with a PPI

- avoid NSAIDs

ReShape Dual Balloon

gastric balloon system that occupies stomach space to induce satiety

- indicated for: BMI 30-40 with at least one comorbidity in patients who have failed diet and exercise

- TBWL after 6 months: 15.4%

- must be removed after 6 months due to risk of obstruction from deflation

- use with a PPI

- avoid NSAIDs

PPIs

which medications should be administered when a patient has a gastric balloon implanted?

NSAIDs

which medications should patients avoid when a patient has a gastric balloon implanted?

Plenity

Nonsystemic, orally administered, superabsorbent hydrogel device; each oral capsule contains carboxymethylcellulose and citric acid, which form a hydrogel matrix when taken with water; the particles rapidly absorb water and mix with food, expanding to fill approximately ¼ of stomach volume, which induces a feeling of satiety (fullness)

- %TBWL demonstrated 6.4% and 9.5% after 6 months and 48 weeks, respectively.

- indicated for Adults with BMI 25 - 40 kg/m2

Take three capsules (2.25 g total) orally twice daily, administer 20 to 30 minutes before lunch and dinner

dosing for Plenity (medical device, not a drug)

3 months

Pharmacotherapy should be discontinued in patients who have not achieved at least 5% weight loss at _____ months of full-dose treatment.

Orlistat (Xenical, Alli: OTC)

lipase inhibitor that blocks gastric and pancreatic lipases in the GIT; prevents absorption of 30% of dietary fat, which is excreted in the feces

- Approved for long-term use in adults and adolescents 12-16 years of age; used as an adjunct to a reduced-calorie diet

- SEs: soft stools, abdominal pain, fecal urgency or incontinence, flatulence, fatty/oily stool

- shows improvement in glucose, TC, and LDL

Xenical; 120 mg TID with each fat-containing meal

Alli: 60 mg TID with each fat-containing meal

- Take during or up to 1 hour after the meal

- Omit dose if meal is occasionally missed or contains no fat

dosing for Orlistat: Xenical and Alli?

- how/when should it be administered?

Interactions:

- impaired absorption of fat-soluble vitamins [DEAK], oral contraceptives, Levothyroxine, Cyclosporine

Contraindications: pregnancy and breastfeeding

Drug interactions and contraindications for Orlistat (Xenical, Alli)

Phentermine-Topiramate ER (Qsymia) [C-IV]

- REMS due to teratogenic effects of Topiramate

sympathomimetic + antiepileptic with weight loss effects via appetite suppression and increased satiety approved for chronic weight management in patients who are obese or overweight with 1 weight-related comorbidity

- if d/c, must taper down gradually to reduce risk of seizure

- SEs: insomnia, cognitive impairment, dry mouth, tachycardia, constipation

Phentermine 3.75 mg and Topiramate 23 mg PO QD x 14 days, then increase to 7.5 mg Phentermine and 46 mg Topiramate PO QD.

- take in the morning due to risk of insomnia

dosing for Phentermine-Topiramate ER (Qsymia) [C-IV]

PREGNANCY (on REMS program due to birth defects)

Hyperthyroidism

Glaucoma

Use within 14 days of MAOIs

contraindications for Phentermine-Topiramate ER (Qsymia) [C-IV]

Bupropion-Naltrexone (Contrave)

dopamine/NE reuptake inhibitor + opioid receptor antagonist approved for longterm use for chronic weight management in patients who are obese and overweight with at least one weight-related comorbidity

- Do not take dose with high-fat meal

- SEs: insomnia, dry mouth, n/v/c, headache

8 mg Naltrexone + 90 mg Bupropion then gradually titrate up to maintenance dose of 16 mg Naltrexone + 180 mg Bupropion (2 tabs) BID

- do not take with fat-containing meal

dosing of Bupropion-Naltrexone (Contrave)

Seizures

Uncontrolled HTN

Chronic opioid use

Pregnancy

Adolescents: increased suicidal ideation (Bupropion)

contraindications for Bupropion-Naltrexone (Contrave)

Liraglutide (Saxenda)

GLP-1 agonist approved for chronic weight management in adults with BMI ≥30 kg/m² or BMI ≥27 kg/m² with ≥1 weight-related comorbidity

- 3 mg SQ once daily (titrate up slowly)

- SEs: n/v/d, abdominal pain, hypoglycemia

- use with caution in renal and hepatic impairment

Thyroid C-cell tumors (BBW)

MEN2

Pregnancy

Contraindications for the GLP-1s

Semaglutide (Wegovy)

GLP-1 agonist approved for chronic weight management in adults with BMI ≥30 kg/m² or BMI ≥27 kg/m² with ≥1 weight-related comorbidity

- 2.4 mg SQ once weekly (maintenance); titrate up slowly from 0.25 mg to prevent SEs

- SEs: n/v/d, abdominal pain, hypoglycemia

- use with caution in renal and hepatic impairment

Tirzepatide (Zepbound)

GLP-1/GIP approved for chronic weight management in adults with BMI ≥30 kg/m² or BMI ≥27 kg/m² with ≥1 weight-related comorbidity

- 2.5 mg SQ once weekly titrate up to 5, 10, or 15 mg SQ once weekly

- proven to cause the most weight loss

- SEs: n/v/d, abdominal pain, hypoglycemia

- use with caution in renal and hepatic impairment

6.5-7.5 lbs

mean body weight reduction with Orlistat (Xenical, Alli)

14.5-18.9 lbs

mean body weight reduction with Phentermine-Topiramate (Qsymia) [C-IV]

10.8 lbs

mean body weight reduction with Bupropion-Naltrexone (Contrave)

11.4 lbs

mean body weight reduction with Liraglutide (Saxenda)

34.1 lbs

mean body weight reduction with Semaglutide (Wegovy)

35-48 lbs

mean body weight reduction with Tirzepatide (Zepbound)

Setmelanotide (Imcivree)

melanocortin 4 (MC4) Receptor Agonist approved for long-term use in patients 6+ with deficiency of POMC, PCSK1, or LEPR. (rare inherited disorders of obesity characterized by early-onset severe obesity and hyperphagia)

- inject 2-3 mg SQ once daily

- Administer at the beginning of the day without regard to timing of meals

Phendimetrazine (Bontril) [C-III]

noradrenergic agent (structurally related to amphetamines) approved for short-term use for weight loss adjunct to diet and lifestyle modifications

- dose: 70-105 mg/day

- Use caution in patients with kidney impairment

- SEs: increased BP, palpitations, tachycardia, dizziness, headache, insomnia, dry mouth

Phentermine (Adipex-P, Lomaira) [C-IV]

noradrenergic agent (structurally related to amphetamines) approved for short-term use for weight loss adjunct to diet and lifestyle modifications

- dose: 8 mg three times daily, given ½ hour before meal

- Use caution in patients with kidney impairment

- SEs: increased BP, palpitations, tachycardia, dizziness, headache, insomnia, dry mouth

Diethylpropion (Tenuate) [C-IV]

noradrenergic agent (structurally related to amphetamines) approved for short-term use for weight loss adjunct to diet and lifestyle modifications

- dose: 75 mg/day (do not administer in evening or at bedtime)

- Use caution in patients with kidney impairment

- SEs: increased BP, palpitations, tachycardia, dizziness, headache, insomnia, dry mouth

multivitamin to prevent vitamin deficiency

what supplement should be taken when on Orlistat (Xenical, Alli)?

week 12

- also d/c if 5% weight loss is not achieved by week 12 on phentermine 15 mg and topiramate 92 mg

Discontinue or escalate dose if 3% weight loss not achieved by week _____ on phentermine 7.5 mg and topiramate 46 mg.

5%

Discontinue Bupropion-Naltrexone (Contrave) if ____% weight loss is not achieved by week 12

4%

Discontinue Liraglutide (Saxenda) if ____% weight loss is not achieved by week 16.

12 to 16 weeks

Discontinue Setmelanotide (Imcivree) if 5% weight loss (or 5% decrease in BMI) not achieved after ____-____ weeks

4 weeks

Discontinue Phendimetrazine (Bontril), Phentermine (Adipex-P), and Diethylpropion (Tenuate) if satisfactory weight loss has not occurred within the first ____ weeks of treatment or if tolerance develops

Hoodia

Green tea

Caffeine

Guarana

Yohimbine

Glucomannan

Bitter orange

list some complementary/herbal supplements that people use for weight loss.