approach to treatment

Question 1

Nonpharmacologic interventions

Answer 1

• Eat real food; mostly plants
• High in fruits and vegetables, colors of the rainbow
• Avoid fruit juice and other sugar laden beverages
• No more than 450 calories or 36 oz. per week
• Drink water!
• Avoid unnecessary sugar, salt, calories or fat
• Exercise: aerobic 150 minutes per week, 3-5 days per week, resistance exercise 2-3 days per week
• Alcohol: men ≤ 2 drinks, women ≤ 1 drink per day
• Avoid supplements
• Limit caffeine

Question 2

Treatment pearls

Answer 2

1. Weight loss of 5-10% of body weight in six months
2. Comprehensive lifestyle management
3. Qualify for pharmacotherapy after 6 months of comprehensive lifestyle management AND one of the following
4. Qualify for bariatric surgery after 6 months of comprehensive lifestyle management AND one of the following
5. Treat other co-morbidities
6. Weight maintenance

Question 3

2. Comprehensive lifestyle management

Answer 3

a. Moderately reduced intake diet
b. Avoid very low calorie diets (<800 kcal/day) except in medically supervised settings
c. Increased physical activity (aerobic >150 minutes/week)
d. Behavioral

Question 4

a. Moderately reduced intake diet

Answer 4

i. Calorie restriction
1. 1200-1500 kcal/day for women
2. 500-1800 kcal/day for men
ii. Energy deficit of 500-750 kcals/day
iii. Evidence-based diets that restrict certain foods
1. High carbohydrate
2. Low fiber
3. High fat

Question 5

b. Avoid very low calorie diets (<800 kcal/day) except in medically supervised settings

Answer 5

i. Risk of complications
1. Rapid weight loss
2. Deficits are too great
3. Nutritional inadequacies
4. No change in behavior
5. Greater risk of gallstones

Question 6

c. Increased physical activity (aerobic >150 minutes/week)

Answer 6

i. Improves psychosocial factors
ii. Avoid weight regain
iii. Reduces risk of morbidity and mortality
iv. Reduce sedentary time
v. FITTE
1. Frequency, intensity, type, time spent, enjoyment

Question 7

d. Behavioral

Answer 7

i. Behavioral economics

ii. Behavioral

Question 8

i. Behavioral economics

Answer 8

1. Cognitive Overload: Decision making or actions are impaired by the complexity of the problem or the large quantity of information (e.g., complex nutritional and cost information)
2. Cues: Items in the environment and/or displays of products that elicit temptation (e.g., appealing food packaging that creates a sense of hunger and a desire for such food)
3. Present Bias: Too great a focus on the present at the expense of future considerations and consequences (e.g., underestimating or ignoring the future health effects of current unhealthy eating habits)
4. Salience: The availability of information at the decision point (e.g., posting itemized nutritional information in a cafeteria setting) physical activity labeling article
5. Self-Control: Willpower to make decisions and behaviors that match long-term plans or goals (e.g., needing self-control to resist the in-store temptations of unhealthy foods)

Question 9

ii. Behavioral interventions

Answer 9

1. Self-monitoring
   a. Amount and types of foods eaten
   b. FITTE of physical activity
   c. Time, place, and feelings
2. Stress Management
   a. Defuse situations that lead to overeating:
   i. Coping strategies
   ii. Meditation
   iii. Relaxation techniques
3. Problem Solving
   a. The self-correction of problem areas related to eating and physical activity
   i. Identify weight-related problems.
   ii. Brainstorm solutions.
   iii. Plan and implement healthier alternatives.
   iv. Evaluate outcomes.
   v. Encourage patient reevaluation of setbacks
4. Stimulus control
   a. Learn to shop for healthy foods.
   b. Keep high-calorie foods out of the home.
   c. Limit the times and places of eating.
   
   5. Contingency Management
      a. Use of rewards for specific actions.
      b. Cannot be food
   6. Cognitive Restructuring
      a. Rational thoughts designed to replace negative thoughts
      b. Instead of. . .
      i. “I blew my diet this morning by eating that doughnut.”
      c. Use. . .
      i. “Well, I ate the doughnut, but I can still eat in a healthy manner the rest of the day.”
5. Social support
   a. Maintain motivation and positive reinforcement
   i. Family
   ii. Friends
   iii. Colleagues

Question 10

3. Qualify for pharmacotherapy after 6 months of comprehensive lifestyle management AND one of the following

Answer 10

a. BMI > 30
b. BMI > 27 with comorbidities (htn, dyslipidemia, coronary heart disease, sleep apnea, DM)
c. BMI > 27 with weight regain on lifestyle therapy
d. Pharmacotherapy effectiveness: If >5% body weight has not been lost in 12 weeks on the medication, consider a switch or discontinuation.

Question 11

4. Qualify for bariatric surgery after 6 months of comprehensive lifestyle management AND one of the following

Answer 11

a. BMI > 40
b. BMI > 35 with comorbidities
c. Can result in vitamin deficiencies and absorption syndromes
d. Medications may work differently post-surgery

Question 12

5. Treat other co-morbidities

Answer 12

i. Treat underlying causes (obesity/physical inactivity)
ii. Intensify weight management

iii. Increase physical activity
iv. Treat lipid and non-lipid risk factors if they persist after 3 months of TLC

v. Treat hypertension
vi. Use aspirin for hypercoagulability

Question 13

6. Weight maintenance

Answer 13

a. Reduced intake diet
b. Frequent self-weighing (at least weekly)
c. Consistent physical activity