Obesity

Classifications, Calculate, Categories of BMI

• Obesity

  • midpoint between lower border of rib cage and iliac crest

    • waist circumference of 35 in women or 40 in men

  • waist to hip ratio - r > 0.85 women or r > 1.0 men

  • Risk factors for - diabetes, heart disease (ASCVD), stroke, cancer, joint problems, psychosocial stress

  • Physiologic Factors - gene pool influences body shape, adiposity, disease susceptibility, weight gain tendency

  • Environmental Factors - support less activity and invite caloric excess through foods, large portions, readily available snack foods causing intake > expenditure

• BMI or body mass index

  • = weight (kg) /height squared (m²)

    • 1 kg = 2.2 lbs, 1 in = 2.54 cm

  • = weight (lbs)/height (in²) x 703

Non-pharmacologic treatment

• Goal - reduce 5-10% body weight from baseline over 6 months at a rate of 1-2 lbs/wk

• behavioral changes skills to be learned focusing on environmental modifications with trained professional

  • Core features - observation, stimulus control, cognitive restructuring, social support, problem solving, relapse prevention

  • SMART goals - specific objectives and goals, measurable change goals, achievable weight loss goals (5-10%), relevant to them, timeline for achieving

• Lifestyle Changes

  • Dietary change - intake calories < output physical activity calories

  • meal planning - based on portion sizes, nutrient composition, food distribution in which intakes facilitate weight control

  • Physical Activity - ADA 150 min/wk moderate-intensity aerobic exercise ± 2 days/wk strength training

    • Modest weight loss 150-250 min/wk

    • Significant weight loss 250+ min/wk

• Bariatric surgery - option when diet,exercise, and behavioral changes fail

  • reducing stomach size (storage space) or nutrient absorption

  • influencing hormones that reduce appetite

List of Weight Gain/Loss Medications

Pharmacological Treatments

• Assessment- If pt does not lose 2 kg in the first 4 weeks of initiation means low likelihood of response. Effective response after 3 months ( 5% or more loss) can continue therapy otherwise D/C

• Phentermine (Adipex-P) - stimulates hypothalamus to release NE for appetite suppression

  • ADR - increase BP/HR, dysrhythmia, dry mouth, insomnia, irritability,

  • Caution - pts with HTN or history of CVD, not guideline recommended

  • CI - combination with monoamine oxidase inhibitors (MAOI)

  • Counsel - should only be used up to 3 months to avoid abuse potential (C3) and tolerance to effect builds up within weeks so D/C dont increase dose

• Orlistat (Alli OTC 60 mg /Xenical 120 mg RX) - inhibits nutrient absorption by forming bond with gastric pancreatic lipase

  • ADRs - GI complaints and decrease absorption of fat-soluble vitamins ADEK separate MV by 2+ hours

  • Caution - hx of nephrolithiasis or pancreatitis

  • Avoid - in pts taking cyclosporine, levothyroxine, anticonvulsants

  • CI - malabsorption disorders, cholestasis, pregnancy

  • Counsel - FDA approved for long term use and most pt lost 5-10 lbs over 6 months PO TID. Take during or up to 1 hour before meals containing fat otherwise omit if < 30 calories from fat.

• Phentermine+Topiramate ER (Osymia) - stimulates NE release for appetite suppression + suppress appetite and enhance satiety

  • ADRs- constipation, dry mouth, paresthesia, insomnia, nasopharyngitis, increase BP, cognitive impairment

  • CI - pregnancy due to REMS fecal defects and oral clefts 1st trime (topiramate)

  • Counsel - FDA approval for long-term use (C4), does require dose titration up and down so D/C if 5% weight loss not achieved after 12 weeks on max daily dose since average weight loss is 8-10%. good for those with seizures

• Naltrexone+Bupropion SR (Contrave) - opioid antagonist + dopamine/NE RI to suppress appetite

  • ADRs - N/V/D, insomnia, Ha, constipation, dry mouth, increase HR and BP

  • BBW to increase suicidal ideation and behavior

  • Avoid - agents lowering seizure threshold or disorder, chronic use of opioids (7 day free recommended)

  • CI - D/C once pregnancy detected

  • Counsel - approved for long term use, titrate dose up weekly, do not take with high-fat meals (increases absorption and concentration), average weight loss of 5-10%

• Liraglutide (Saxenda) and Semaglutide (wegovy) - glucagon like peptide-1 (GLP-1) receptor agonist

  • ADRs - N/V/D, GERD, injection site reaction, can enhance hypoglycemia of other diabetes meds

  • Caution - hx of nephrolithiasis or pancreatitis, GI disorders (constipation, bowel obstruction)

  • BBW for risk of Thyroid C-Cell tumors

  • Counsel - FDA approved for long-term use Saxenda 10% weight loss, Wegovy 15% weight loss

• Tirzepatide (Zepbound) - dual glucose dependent insulinotropic polypeptide (GIP) and glucagon like peptide-1 (GLP-1) receptor agonist

  • ADRs - N/V/D, GERD, injection site reaction, can enhance hypoglycemia of other diabetes meds

  • Caution - hx of nephrolithiasis or pancreatitis, GI disorders (constipation, bowel obstruction)

  • BBW for risk of Thyroid C-Cell tumors

  • Counsel - pts on oral hormonal contraceptives should use a back-up method for 4 weeks after initiation and dose escalations, average 15-25% weight loss at 72 weeks, fda approval for long term use