Obesity and Weight Management Flashcards
What is obesity?
A chronic,
progressive, relapsing, and treatable multifactorial, neurobehavioral disease,
wherein an increase in body fat promotes adipose tissue dysfunction and
abnormal fat mass physical forces, resulting in adverse metabolic,
biomechanical, and psychosocial health consequences
How to classify obesity?
BMI
What are the classifications of BMI?
What is the Edmonton Obesity Staging System (EOSS)?
What is the American Association of Clinical Endocrinologists
Obesity Classification?
More than ___% of adults in the US are obese
40%
Obesity is the ___ leading cause for preventable death
Second
What are some contributing factors to obesity?
Genetic, environment, development, behavior
Describe the genetics of obesity
Monogenic vs. polygenic
Monogenic: early onset, severe obesity, rare, variation in single gene, alleles with high penetrance, no environmental influence
Polygenic: common, modest genetic influence, several variants, alleles of low penetrance, environment is a key factor in
expression
What are some genetic abnormalities and syndromes that are associated with obesity?
What is MC4R deficiency?
Hyperphagia, accelerated linear growth, insulin resistance
Autosomal dominant or recessive
Most common form of monogenic obesity
What is POMC Deficiency?
Hyperphagia, ACTH deficiency, hypopigmentation, pale skin, red hair
Autosomal recessive
What is leptin deficiency?
Hyperphagia, hypogonadism, absence growth spurt, impaired T cell function
Autosomal Recessive
What is Bardet-Biedl Syndrome?
Hyperphagia, vision loss, polydactyly, hypogonadism, renal disease, metabolic syndrome
Autosomal recessive
What is Cohen Syndrome?
Central obesity with thin arms/legs, small head with thick hair, eyebrows,
eyelashes, developmental delay, retinal dystrophy, joint hypermobility,
overly friendly behavior, neutropenia
Autosomal recessive
What is Prader-Willi Syndrome?
Hypotonia and poor feeding at birth, hyperphagia develops at 2 years,
thin face with almond shaped eyes, short stature with small
hands/feet, delayed development and intellectual impairment,
hypogonadism
Parental chromosome 15 partial loss of function (usually not inherited)
Most common form of syndromic obesity
Significant increase in ghrelin in PWS
What is Albright’s Hereditary Osteodystrophy?
Short stature, round face, dental abnormalities, shortened fingers/toes,
pseudohypoparathyroidism
Associated with genetic imprinting in an autosomal dominant manner
Describe specific epigenetic factors that play into obesity
DNA methylation, histone modification, RNA based mechanisms
Describe specific environmental factors that play into obesity
Diet, activity, aging, smoking, toxin exposures, sleep, stress, learned patterns
Describe specific social factors that play into obesity
Lack of green space, lack of safety, food deserts, food insecurity, low socioeconomic status, low education,
dietary
What are the forms of energy expenditure?
Resting metabolic rate - 60%
Physical activity - 30%
Thermic effects of food - 10%
What are the signaling pathways for the gut-brain axis?
- Hormonal
- Neuronal (vagus nerve)
- Orexigenic (appetite stimulant)
- Anorexigenic (appetite suppressant)
What role does our brain play in appetite
regulation?
Homeostatic eating: when we are
depleting our energy stores we have
increased motivation to eat
Hedonic eating: increased desire to
consume foods that are
highly palatable
Executive function: overriding any signaling and
deciding to eat or not eat
What are some hormonal factors that are involved in appetite regulation?
What are orexigens?
Appetite stimulants - increase intake
What are some examples of orexigens?
Neuropeptide Y (NPY)
Agouti-related protein (AgRP)
Orexin A and Orexin B
Melanin-Concentrating Hormone (MCH)
What are anorexigens?
Appetite suppressants - reduce intake
What are some examples of anorexigens?
Proopiomelanocortin (POMC)
Cocaine amphetamine regulating transcript (CART)
Alpha melanocyte stimulating hormone (alpha-MSH)
Brain derived neurotrophic factor
Serotonin
What is ghrelin?
Growth Hormone Release Inducing Peptide
AKA “the hunger hormone”
Orexigenic
Signal to release ghrelin is an empty stomach
Levels increase and peak prior to eating, levels decrease when nutrients are ingested
What increases ghrelin?
Fasting, weight loss, stress and sleep deprivation, genetic syndromes
What reduces ghrelin?
Meals, weight gain (stomach stretching), leptin, sleeve gastrectomy
What is cholecystokinin (CCK)?
Produced by l-cells in proximal small bowel (duodenum/Jejunum)
Secreted after fat/protein ingestion and stomach distension
Short acting peak at 15-30 minutes from meal initiation
Stimulates gallbladder contraction, slowing stomach emptying, reducing appetite
Receptor in GI tract and brain
What is Glucagon-Like Peptide 1 (GLP-1)?
Produced by L-cells of the ileum and proximal colon
Secretion stimulated by nutrients, neural, and endocrine factors after eating
GLP-1 receptors found in heart, kidney, lung, pancreas, CNS, PNS
It is an incretin, anorexigenic
GLP-1 levels are reduced in obesity, prediabetes, type 2 diabetes
What is Glucose-Dependent Insulinotropic
Polypeptide (GIP)?
AKA gastric inhibitory peptide
Incretin hormone, released by K cells in the duodenum and upper jejunum
Released in response to oral glucose load
GIP and GLP-1 together are responsible for up to 70% of the postprandial insulin
response
Reduces nausea and stimulates glucagon secretion
What is Oxyntomodulin (OXM)?
Incretin, produced by L-cells in distal small intestines and colon
Co-secreted upon eating (made by same precursor as GLP-1)
Produced postprandially and actives multiple receptors
Exogenous administration can cause weight loss (decreasing appetite and feeding,
increasing energy expenditure)
What is Peptide YY (PYY)?
Anorexigenic, produced by L-cells in distal small intestine, colon and rectum
Potent appetite suppressant
Increases within 1 hour of feeding; delays gastric emptying and intestine transit time
What is Pancreatic Polypeptide (PP)?
Released in response to calorie load; reduces gastric emptying in gut and reducees hunger expression in hypothalamus
Low levels in fasting state
Patients with obesity and Prader Willi Syndrome have lower levels of PP
What is insulin?
Released in response to eating
It is one of the long-term adiposity signaling hormones
Centrally reduces appetite in hypothalamus
Similar effect to leptin in the CNS but less potent
Resistance attenuates weight loss effects centrally
In muscles: uptakes glucose (glycogen), uptake amino acids (protein)
In liver: stimulates uptake glucose (glycogen), inhibits conversion fat and protein (glucose)
In adipose: stimulates fat synthesis
What is amylin?
Amino acid hormone co-secreted with insulin by beta cells, makes insulin more effective
Secreted in response to meals
Regulates glucose and bodyweight by reducing food intake, slowing gastric emptying,
suppressing glucagon production in the liver
Effects are similar to GLP-1 (milder glucose reduction and weight loss)
What is leptin?
Secreted by adipocytes in white adipose tissue; secretion is diurnal
Major role in energy balance
Circulating levels directly proportional to body fat mass
Crosses BBB and binds to the hypothalamic leptin receptors
Can activate the sympathetic nervous system
Interacts with gonadotropin pulse generators in the hypothalamic pituitary gonadal axes
Has regulation of immune function, hematopoiesis and angiogenesis
What is adiponectin?
Improves insulin sensitivity in skeletal muscle, improves insulin sensitivity in liver, reduces
vascular inflammation
Most abundant hormone secreted by adipocytes
Levels inversely related to body fat mass
Liver activity: enhances insulin sensitivity, decreases non-esterified fatty acids, increases
fatty acid oxidation, reduces liver glucose output
Muscle activity: stimulates glucose use and fatty acid oxidation
Vascular endothelium activity: inhibits monocyte adhesion, inhibits macrophage
How does a lap band procedure impact gut hormones?
Increases ghrelin, increases PYY, reduces insulin, reduces leptin
How does a gastric sleeve procedure impact gut hormones?
Large reduction ghrelin, increases GLP-1, increases PYY, decreases insulin, decreases leptin
How does a gastric bypass procedure impact gut hormones?
Variable ghrelin, large increase in GLP-1, increases PYY, increases OXM, reduces Insulin, reduces Leptin
What are some metabolic manifestations of obesity?
Chronic positive energy balances lead to?
Adipocyte hyperplasia (lots of small adipocytes)
Adipocyte hypertrophy (few large adipocytes)
What are weight circumference classifications?
What are 5 criteria for metabolic syndrome?
Obesity may (increase/decrease?) pro-inflammatory macrophages
Increase
M1 Macrophages increase with obesity and secrete proinflammatory factors (TNF, IL-6, MCP-1)
M2 macrophages predominate in lean individuals and secrete anti-inflammatory factors
In obesity M1/M2 proportion is polarized towards proinflammatory
What is hepatosteatosis (MASLD: metabolic dysfunction associated steatotic liver disease AKA
NAFLD)?
Mitochondrial
dysfunction and endoplasmic reticulum stress create reactive oxygen species, releasing
cytokines, insulin resistance and cellular apoptosis
Increases in circulating proinflammatory factors and decreases in anti-inflammatory factors may
promote inflammation and liver fat accumulation
What is hepatosteatitis (MASH)?
Hepatocyte injury and death from intracellular accumulation of fatty acids, cholesterol and
other toxic lipids and from ROS
Cellular death promotes inflammatory responses
Fibrosis develops –> cirrhosis –> end stage liver disease –> increases risk of need for liver transplant and hepatocellular carcinoma
Evaluating obesity and liver disease (labs)?
Fasting glucose, A1c, hepatic panel, fibrosis 4 index panel, serum biomarkers, imaging, liver biopsy
Liver biopsy is gold standard to assess fat and fibrosis but is not routinely done
What is the relationship between obesity and cardiovascular disease?
Increased visceral and epicardial fat increase the risk of atherosclerotic CV disease –> increased coronary artery calcification
Increased fat mass compress veins and impair venous blood return which increases/promotes thrombosis
Cardiac remodeling (LVH, atrial enlargement, fat deposition –> fibrosis)
Activation of sympathetic nervous system increases BP
Activation of the RAAS causing elevated BP
Inflammatory effects –> vasoconstriction and arterial stiffness
Reduction in HDL, increase in LDL, increase in VLDL, increase in small, dense LDL particles
What is the relationship between obesity and sleep apnea?
> 80% of adults with OSA are overweight
> > 50% of adults with OSA have obesity
Is a vicious cycle
Alter in the circadian system –> altered feeding, changes to body composition, increased
blood sugar, higher blood pressure, higher cholesterol, increased risks of heart disease and stroke
What is the relationship between obesity and osteoarthritis?
Obesity increases the load and impact on the cartilage of the knee
Obesity also causes systemic metabolic factors and adipokines may influence cartilage
homeostasis
Obesity/overweight also risk factor for hip OA
Can be worse for women in perimenopause/menopause/postmenopausal
Is there an associated between obesity and cancer?
Yes
What is the relationship between obesity and perimenopause/menopause?
Declining estrogen = increased leptin, decreased ghrelin and NPY
Body composition changes (increased fat mass, increased adiposity, loss free fat mass)
Increased risks of CV disease (2-4 x higher rates)
Elevated blood pressure, elevated LDL, weight gain, loss lean muscle mass, reduced activity levels, dietary changes, food preference changes
Sarcopenic obesity
What is the relationship between obesity and stress?
Long-term stress can result in an increase in hypothalamic corticotropic activity: increases in blood cortisol, can worsen sleep patterns, increase food cravings
Increase BP, worsen metabolism, cause dysregulation in the immune responses
Greater weight loss (improves/worsens?) obesity-related complications
Improves
What are important history components to obtain for obesity?
Notes: EtOH has a lot of empty sugars, traveliing a lot and thus eating out/fast food a lot?
Physical exam components for obesity?
Vitals: height, weight, BP, BMI, HR, respirations, O2, waist circumference, hip circumference, neck circumference
Labs for diagnostic testing for obesity?
CBC, CMP, fasting lipids (esp. triglycerides and HDL), A1c, TSH, vitamin D
Of note: accurate triglycerieds needs to be from a fasting state
Additional diagnostic labs to consider for obesity
Additional diagnostic labs to consider for obesity
What are some examples of body composition evaluations?
What is fat-free mass?
Total body mass (muscle, organs,
water, bones, ligaments, tendons)
Includes water, mineral, protein and glycogen
DXA measures fat, soft tissue and bone
FFM = total mass - fat mass
What is lean body mass?
Total body mass (muscles, organs, water, bones, ligaments, tendons), less non essential or storage
adipose tissue
Includes water, mineral, protein, glycogen, essential fat
in organs, CNS and bone marrow
Usually only differs from FFM by ~5%
Total body mass = fat mass + lean mass + bone mass
Lean mass = total mass - fat mass-BMC
% body fat = Fat mass/(total body mass-bone mass)
What are types of energy expenditures?
Basal metabolic rate, resting metabolic rate, cellular respiration, direct calorimetry, indirect calorimetry
What is basal metabolic rate?
Energy expended while
fasting, rested and supine in thermoneutral environment
What is resting metabolic rate?
Energy expended at rest, doesn’t require overnight supine measurement
What is cellular respiration?
Converts biochemical energy like food into heat and cellular energy
What is direct calorimetry?
Measure heat generated by organism, measures difference in temperature of water entering and leaving the chamber via heat exchanger
Value of generated heat can estimate total energy expenditure
Enclosed calorimeter
What is indirect calorimetry?
Estimate basal EE and resting EE by measuring O2 consumption
VO2 and CO2 production VCO2
Resting metabolic rate can be estimated by what types of equations?
Most common: Harris-Benedict, Mifflin St. Jeor
Physical activity can be measured or estimated by?
Activity records as data to validated
EE tables
Calculations based on HR
Motion sensors (pedometers)
Accelerometers
How to structure obesity treatment (hint: pyramid)?
Lifestyle modifications for obesity treatment?
Eating plans/Nutrition
Activity
Behavior techniques
Other health factors
Stress management
Sleep
What are the 3 macronutrients?
Carbohydrates, lipids, fats
Describe carbohydrates
Source of energy and provide cellular structural elements
Includes: starches, sugars, fiber
4 kcal/gram (except for fiber)
Satiation is dependent on presence of fiber
Glucose stored as glycogen in muscle and liver. If positive caloric
balance then glucose converted to fat in the liver and is stored as
adipose tissue
Dietary reference intake: at least 130 g per day
Simple: mono and disaccharides - table sugar, dairy products,
malt sugar. Broken down during digestion into glucose,
galactose, fructose
Complex: poly and oligosaccharides; starches and high fiber
foods like whole grains, beans, fruits/vegetables
Whole grain carbs REDUCE CVD risk
45-65% total daily intake
Describe dietary fiber
Is a carbohydrate
Some are fermentable - low, moderate and high: low (cellulose, hemicelluloses, wheat bra), moderate (beta-glucans, gums, pectin, resistant starch), high (inulin, oligofructose)
Soluble, viscous fiber could help reduce blood cholesterol and improve glycemic control
Fiber can also increase satiety and help gut microbiome
20-35 grams per day
Describe other types of sugars/carbohydrates
Glucose is a simple sugar found in fruit (glycemic index of 100)
Fructose is found in fruit (GI of 25)
Sucrose (disaccharide of glucose + fructose derived from sugar cane or beets) has GI of 65
High fructose corn syrup: artificial sweetener, derived from corn starch glucose syrup processed into fructose; is a liquid containing unbound glucose and fructose and has a GI of ~70
Excessive intake of HFCS can lead to obesity, FLD, hypertriglyceridemia and DM
Limit added sugars to < 10% total daily intake
Describe fats
Used as energy source for many metabolic processes including immune response, cell membrane, brain, synthesis of bile acid, cholesterol, vitamin D and steroid hormones and for insulation
Dietary reference intake: at least 30 g/d
Polyunsaturated, monosaturated, transsaturated, saturated
Essential fatty acids are Omega 3 and Omega 6 fatty acids
Endogenously derived essential fatty acids like EPA, DHA (both omega 3 fatty acids), and Gamma linolenic acid (omega 6 fatty acid)
20-35% total daily calories
What are transsaturated fats?
INCREASE CVD risk
Artificially are partially hydrogenated vegetables oils, naturally are conjugated linoleic acid from ruminants and has no detriments to health. Artificials are associated with increased LDL, reduced HDL, increased CV disease, diabetes and cancers. Can find them in microwavable foods, margarine, crackers, fried fast foods, frozen pizza
What are saturated fats?
Short chain: created and absorbed in intestine as result of fiber fermentation, medium chain - transported into portal vein after digestion and can induce ketosis (MCT oil tx of epilepsy)
Long chain: found meats, dairy, tropical oils, hydrogenated vegetable oils like shortening
What are polysaturated fats?
REDUCE CVD risk
Simple molecules, plant based oils typically liquid at room temp, they provide essential fats like Omega 6 and Omega 3. Nuts contain both poly and monounsaturated fats
What are monosaturated fats?
REDUCE CVD risk
Liquid at room temp, found in plant foods (nuts, avocados, olives,
canola oils, vegetable oils)
Describe proteins
Contains 4 kcal/gram
Amino acids, serve as building blocks
Essential AA are those we cannot make and must consume
Protein restriction may delay progression to dialysis for CKD patients
Protein deficiency: Kwashiorkor
Dietary reference intake 0.8-2.0 grams/kg/day (dependent on age, gender, activity, health)
Complete proteins have all 9 essential amino acids
Incomplete proteins lack 1 or more AA but can be combined to form a complete protein
10-35% of total daily intake
What is a good rule of thumb for macronutrient ratios?
30/30/30
30% carb, 30% fats, 30% protein
What does calorie restriction look like?
Low Calorie: Women 1000-1200 kcal/d, Men 1200-1600 kcal/d
Describe fat restriction
Fat restriction: low fat < 30% fat calories OR very low fat: < 10% fat calories to minimum of 30 g/day
After 6 months can produce similar weight loss ot low carb diet
May reduce fasting glucose, insulin level and modest reduction in BP
Modest decrease in LDL and HDL
Risk of deficiency if consuming <30 g/d or 270 kcal
Describe carb restriction
Carb restriction: low glycemic OR low carb:< 130 g/d or < 26% calories OR very low carb: < 50 g/d
Modest weight loss for first 6 months, after that weight loss is similar to other calorie restricted diets
Reduces fasting glucose, insulin and triglycerides
Increases HDL and may lower LDL
Modest reduction in BP
Metabolic changes with or without weight loss
Epilepsy patient’s using the very low carb/ketogenic diet can reduce seizures
Low carb may improve DM complications like neuropathy
May induce gout flares, could result in malaise, could be challenging in patients with protein restriction (CKD), monitor for low blood sugar and BP and adjust meds as needed
Describe very low calorie weight restriction
< 800 kcal/d
CLINICAL SUPERVISION
SHORT DURATION
Meal replacements
May need supplementation due to micronutrient deficiencies
Produces rapid weight loss
Beneficial for pre surgical preparation
Reduces fasting glucose, insulin and triglycerides, increases HDL, decreases LDL, reduces BP
Adverse effects - fatigue, nausea, constipation, diarrhea, hair loss, brittle nails, cold intolerance,
dysmenorrhea, slight increased risk of gallstones, kidney stones and gout flares
Increased risk of cardiac dysrhythmias and muscle cramping if micronutrient deficiencies
Weight regain will occur if not taught how to maintain when transitioning back to different diet
Describe the Mediterranean diet
Olive oil as main source of fat
Vegetables 3-9 servings
Whole fruit 0.5-2 servings
Whole grains/legumes 1-13 servings per day
Moderate intake of red wine
Moderate consumption of seafood, fermented dairy products, poultry, nuts,
seeds, eggs
Limit red meat, meat products, ultra processed carbs
Saturated fats minimal
Describe the DASH diet
Dietary approaches to stop hypertension
Primarily to treat HTN/High BP
Vegetables, fruits, whole grains, fat free or low fat dairy, fish, poultry, lean meats, nuts, seeds, legumes, fiber, calcium, potassium, magnesium
Limit sodium 1500-2300 mg/d
Limit total fat ~27% total calories per day
Limit saturated fat < 6% total daily calories
Limit cholesterol < 150 mg per day for 2100 calorie eating plan (adjust accordingly)
Avoid red and processed meats, sugar sweetened beverages, and foods with ADDED sugars
Describe the Therapeutic Lifestyle Change
diet
Low fat meal plan recommended by National Cholesterol Education program, Adult Treatment
Panel
Utilized in lipid clinical trials
Includes physical activity and smoking cessation
Total fat: 25-35% daily calories
Limit sat fat < 7%
Limit cholesterol < 200 mg/d
Avoid trans fatty acids
Describe the ornish diet
Very low fat restriction, foods eaten in natural form
Vegetables, fruits, legumes, whole grains
Small meals eaten frequently
Limit dietary fat < 10% total daily calories
Dietary cholesterol < 10 mg per day
Limit sugar, sodium, alcohol
Avoid animal products and caffeine
Avoid trans fatty acid, refined carbs, and oils
Describe the vegetarian diet
Foods that come mostly from plants
AVOID ultra processed foods, fried foods, and refined carbs - negates the benefits of vegetarian diets
Monitor for deficiencies like Vitamin B12
What are subtype of the vegetarian diet?
Vegan: ONLY plant based foods, no animal proteins or by products
Lacto vegetarian: plants + some or all dairy products
Lacto-ovo vegetarian: plant, Dairy and eggs
Semi or partial vegetarian: plant, may include some chicken/fish, dairy, eggs, NO red meat
Pescatarian: plant + seafood
Flexitarian: mostly plant based, occasional fish, meat, animal products
Describe the paleolithic (“paleo”) diet
Based on diet presumed to have excited during the Paleolithic
period
EXCLUDES grains, dairy, ultra processed foods
Fresh vegetables, fruits, root vegetables
Grass fed lean red meats, fish and seafood, eggs, nuts/seeds
Naturally produced oils (olive, walnut, flaxseed, macadamia,
avocado, coconut)
AVOID: cereal grains, legumes (includes peanuts), dairy, potatoes,
ultra processed foods, refined sugars, refined oils, and salt
Describe the ketogenic diet
Car-restriction promoting utilization of fat for energy, generates ketosis
Encourage balance of saturated, monounsat and polyunsaturated fats
Need vitamin and fiber supplementation
Avoid ultra processed, refined, high glycemic index, trans fatty acid foods
Generally limit cereals, breads, grains, dairy ( except cheese), starchy vegetables, most fruits
Benefits: weight loss, reduce hunger, lower postprandial glucose and insulin, may improve glucose metabolism (insulin sensitivity, reduced fasting glucose and insulin), reduce diastolic BP, reduce TG and increase HDL, ketonemia can treat seizures, adjunct to certain kinds of cancer therapy
Risks: may increase LDL (can avoid by eating polyunsat versus sat fats), no improvement in insulin sensitivity if no weight loss, transient fatigue, mild decrease in cognition (upon start of diet), physical performance changes
What are the phases of the keto diet?
Induction phase: <= 20 g carbs per day non starchy vegetables, leafy greens and adequate protein to reduce insulin and generate ketosis
Ongoing weight loss phase: wider variety vegetables, seeds, nuts and low glycemic whole fruits like strawberries and blueberries
Pre Maintenance Phase: once goal weight achieved, allow carb intake to slowly increase while monitoring weight
Maintenance phase: 60-90 g of carbs per day if weight and health maintained; may include legumes, whole grains and whole fruits
Is intermittent fasting and
time-restricted eating as effective as continuous calorie restriction?
Yes
What are advantages of intermittent fasting and
time-restricted eating?
Reduced decision fatigue, quickly reversible, may fit better in day to day schedule, may reduce caloric intake, may improve metabolic parameters and reduce body weight
What are disadvantages of intermittent fasting and
time-restricted eating?
Does not necessarily emphasize “healthy” meal quality, may not want to use in patients with eating disorder history, increases risk of hypoglycemia, no great evidence of sustainability, long-term evidence of benefits/safety/efficacy from animal studies, Prolonged fasting may promote gout, urate nephrolithiasis, postural hypotension and dysrhythmias
What are physical activity recommendations per week?
150-300 minutes + moderate-intensity activity OR 75-150 min+ vigorous intensity activity per week
Muscle strengthening activities 2+ days per week
Moderate intensity: brisk walk, raking yard, etc
Vigorous intensity: running, weight lifting, fitness class
Moderate or vigorous: swimming, bicycling
For clinically significant weight loss and maintenance activity should be 250 min or greater per week
Resistance training can improve the proportion of fat to fat free mass loss
Without weight loss it still improves health risk
What are some behavioral techniques for weight managment?
Motivational interviewing
Having empathy
Going through the 5 A’s
Address body image
Why do we eat like we do?: physiologic, stress, emotions, timing, environment, information
gap, reward
Why DON’T we engage in routine activity?: physical symptoms, lack of time, not interested,
support, inadequate education, financial, accessibility
Elements for success: doable, evidenced base, measurable, accountability, ownership,
frequent encounters (medical professionals), education, setting goals, non scale goals, self
monitoring, stimulus control, addressing body image, creating plan to change cognitive
patterns, rewards, stress mgmt, health care team, group support, weight loss programs, use
of technology and social media and telemedicine
Stress management
Improving sleep
Mindful eating
Meds that can cause obesity
Beta blockers, calcium channel blockers, insulin, sulfonylureas, steroids, progestion contraceptives, gabapentin, valproate, some antipsychotics, lithium, some SSRIs and SNRIs, many others…
Obesity meds
Phentermine/topiramate, liraglutide, semaglutide, naltrexone/bupropion, tirzepatide, orlistat
Phentermine
Lomaira/Adipex
Reduces appetite
CI: uncontrolled HTN, uncontrolled anxiety, CV history, hyperthyroidism, there is risk mania, pregnancy
Monitor: BP, pulse, EKG (person dependent)
AEs: constipation, dry mouth, headache, insomnia, anxiety, jitteriness, palpitations, elevated HR and BP
Caution > 65 years old
FDA approved, approved for pediatrics
Topiramate
Topamax
Disinterest in food, reduces cravings, less food thoughts
Think about using in patients with migraines, insomnia, pain
CI: hx of calcium kidney stone, glaucoma, cognitive impairment, risk of birth defects (teratogenic)
Monitor: BMP, mental status
AEs: drowsiness, paresthesia, memory issues, word finding difficulty, taste changes
Caution in elderly, CKD, uncontrolled depression
Rare risk of metabolic acidosis
NOT FDA approved
Phentermine/Topiramate
Qsymia
CI: same as individual medications
Monitoring: same as individual medications
AEs: same as individual medications
FDA approved, approved for pediatrics
Lisdexamfetamine
Vyvanse
Causes appetite suppression
CI: uncontrolled HTN, anxiety, CV history, risk mania
Monitor: BP, pulse, EKG
AEs: constipation, dry mouth, headache, insomnia, anxiety, jitteriness, palpitations, dizziness, nausea, vomiting, increased HR, anorexia
Caution> 65 years old
Use for moderate to severe binge eating disorder and ADHD
Approved for pediatrics
Naltrexone
Revia
Works in mesolimbic reward pathway to decrease cravings
Dose around time of largest cravings
CI: if taking opioids, upcoming surgery, severe hepatic injury
Monitor: LFTs
AEs: nausea, dizziness, headaches, anxiety, insomnia is limited
NOT FDA approved
Naltrexone/Bupropion
Contrave
Naltrexone mechanism + bupropion mechanism which stimulates POMC reducing
hunger.
CI: concurrent use MAOI, opioids or CYP2B6 inducers, hx of seizures, active bulimia/anorexia, uncontrolled HTN/anxiety
Monitor: BP, HR, LFTs, mental status
Hepatic and renal dosing
AEs: headache, insomnia, nausea, constipation, vomiting, dizziness, dry mouth, tremor
Orlistat
Xenical or Alli
Mechanism: GI lipase inhibitor that impairs digestion of dietary fat
AEs: oily stools, oily flatus worse after fatty meals. Can promote kidney and gallstones and malabsorption of fat soluble vitamins
CI: chronic malabsorption syndrome and cholestasis
Drug interactions: cyclosporine, oral contraception, anti seizure medications, thyroid
hormone, warfarin
Not often used d/t AEs
FDA approved, approved for Peds
SQ Peptide Medications
Ex: GLP/GIP (semaglutide/Wegovy; liraglutide/Saxenda)
CI: personal or FH medullary thyroid carcinoma, MEN2, idiopathic/chronic pancreatitis or pancreatitis from GLP 1 agonist.
Exenatide if GFR< 30 ml/min
Monitor: A1c, blood sugars as needed, BMP
AEs: nausea, diarrhea, constipation, headache, heartburn, gallstones, pancreatitis, gastroparesis, fatigue
Tirzepatide/Zepbound: weekly 2.5 mg, 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg
FDA approved, semaglutide and liraglutide approved for pediatrics
Non-Systemic Oral Hydrogel
Biodegradable oral non-systemic superabsorbent hydrogel
Promotes fullness
CI: pregnancy, hx of reaction to cellulose, citric acid, sodium stearyl fumarate, gelatin, titanium
oxide
AEs: abdominal pain, constipation, flatulence, infrequent bowel movements, abdominal distension, diarrhea, nausea
FDA approved
Setmelanotide
Imcivree
Melanocortin-4 receptor agonist: use in those with Bardet-Biedl syndrome (clinically diagnosed), POMC, PCSK1, LEPR deficiency (must be confirmed by genetic testing)
Discontinue if after 12-15 weeks of tx there is not at least 5% loss of baseline bodyweight
AEs: injection site reaction, skin hyperpigmentation, nausea, headache, diarrhea,
abdominal pain, back pain, fatigue, vomiting, depression, URI, spontaneous erections
FDA Approved
Metreleptin Subcutaneous Injection
Myalept
Leptin Analog
Adjunction to diet to treat complications of leptin deficiency
Not indicated for patients with NASH or HIV related lipodystrophy
CI: hypersensitivity, general obesity not associated with congenital
leptin deficiency
AEs: headache, hypoglycemia, decreased weight, abdominal pain
Types of bariatric surgery
VSG (Vertical Sleeve Gastrectomy)
RYGB (Roux-en-Y gastric bypass)
LAGB (Laparoscopic Adjustable
Gastric Banding)
Balloons 4,358 (1.6%)
Revision
Who should undergo surgery?
BMI >= 40
Those who are not responding to non surgical weight loss management AND BMI >=35 regardless of comorbidities
BMI 30-34.9 and metabolic disease
BMI >=27.5 in Asian populations
Appropriate pediatric patients
Who should not undergo surgery?
Severe heart failure, unstable CAD, end-stage lung disease, Active cancer treatments, portal
hypertension, decompensated liver cirrhosis, drug and alcohol dependency
Vertical Sleeve Gastrectomy (VSG)
Most common surgery
Can worsen GERD and Barretts
Favorable changes in gut hormones for hunger, satiety, blood sugar control
Common deficiencies: Vitamin B1, B9, B12, D, Iron
Roux-en-Y Gastric Bypass (RYGB)
Favorable changes in gut hormones and neuroendocrine
signaling
Bypasses part of the small intestine which limits absorption
Resolves GERD
Good for those at higher BMI, GERD, and Type 2 diabetes
Common Deficiencies: Vitamin B1, B9, B12, D, calcium, Iron
Laparoscopic Adjustable Gastric Banding
Least invasive, removable (not permanent)
Metabolic benefits are dependent on amount of weight loss
Ideal for those with low BMI and no metabolic conditions
Lowest rate of complications
Common Deficiencies: Vitamin B1, D
Nonsurgical procedures for weight loss
Intragastric balloons, electrical vagal blocking system, endoscopic sleeve gastroplasty (ESG; doesn’t affect ghrelin secretion)
Bariatric surgery postop diet pearls
3-5 small meals per day
Decrease in # of meals as portion size increases
Chew thoroughly
Avoid consuming liquids during meals
Protein at least 60 g/d (1.2-1.5 g/kg/d of lean mass)
Avoid excessive calorie intake
High quality multivitamins - chewable or liquid
What is dumping syndrome?
Complication of RNY because it bypasses the pyloric emptying mechanism; common
Facial flushing, lightheadedness, fatigue, reactive hypoglycemia, postprandial diarrhea
Tx: avoid high glycemic index foods, avoid drinking fluid with meals
Can adolescents use pharmacologic therapy for weight loss?
Yes
AAP Recommendations: SHOULD offer adolescents 12 years and older obesity weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle management
Some options: liraglutide, semaglutide, topiramae, vyvanse
