Obesity and Weightloss

Question 1

Body Mass Index (BMI): Calc + Classification

Answer 1

BMI = weight (lb) * 703 / height^2 (in^2)
BMI = weight (kg) / height^2 (m^2)

• 1 kg = 2.2 lbs
• 1 in = 2.54 cm = 0.0254 m

< 18.5 : Underweight
18.5-24.9 : Normal
25 - 29.9 : Overweight
30 - 39.9 : Obese
> 40 : Morbidly obese

Question 2

Ideal Body Weight (IBW)

Answer 2

Men
- IBW : 50 kg + 2.3 kg * every in over 5 ft

Women
- IBW : 45.5 kg + 2.3 kg * every in over 5 ft

Question 3

Weight Gain

Answer 3

• Energy intake > Energy Expenditure

* 1 lb of adipose tissue = 3,500 calories

Question 4

Risk Factors

Answer 4

Environment
• Lifestyle
- Increased portion sizes and calories 
- Increased work hours
- Decreased exercise
- Decreased sleep

• Genetics

• Increased storage of body fat
• Hormones
• Leptin
• Ghrelin

Question 5

Medication Causing Weight Gain

Answer 5

• Atypical and Typical Antipsychotics

• Clozapine
• Olanzapine
• Haloperidol

• Antidepressants

• Tricyclics
• Monoamine oxidase inhibitors
• Mirtazapine

• Insulin

• Corticosteroids
- Hormonal contraceptives

• Anticonvulsants

Question 6

Weight Management: Exclusion for Self-Treatment

Answer 6

1. Severe Obesity (BMI ≥ 40)
2. Pregnancy or Breastfeeding
3. Age (< 18 or > 65 years old)
4. Cardiovascular Disease
5. Hypertension, Diabetes, Dyslipidemia
6. Eating Disorders

Question 7

Dietary Change: Avg. for M/W, Caloric Restriction

Answer 7

• Average caloric intake for a 30-year old

• Men: 2,200-3,000 kcal/day
• Women: 1,800-2,800 kcal/day

• Restriction: ↓ 300-1000 kcal/day

• Low Calorie Diet (LCD): ↓ 1-2lbs/week
- 800-1,500 kcal/day

Question 8

The Very Low Diets (Cals, Requirements, AE)

Answer 8

Very Low Calorie Diet (VLCD)
• < 800 kcal/day, at least 1g/kg protein
• Requires supervision/monitoring

Multivitamin for diets < 1,200 kcal/day

Starvation
• Depletes body of lean tissue (protein), electrolytes, and fat

Adverse Effects
• Fatigue
• Hair loss
• Dizziness
• Diarrhea
• Constipation
• Dry skin
• Irregular menses
• Gallstones

Question 9

Calories

Answer 9

• Protein = 4 kcal/g
• Carbohydrates = 4 kcal/g
• Fat = 9 kcal/g
• 1 Calorie = 1 kcal
• 1000 calories = 1 kcal

Question 10

Dietary Change: Altered Food Groups

Answer 10

NHLBI Recommendation
• Fat ≤ 30% (8-10% comes from saturated fat)
• Protein ≈ 15%
• Carbohydrates ≥ 55%

Glycemic Index
• Amount of rise in blood glucose after eating

Question 11

Not All Additives Created Equal…

Answer 11

• Sugar alcohols (sorbitol, xylitol, maltitol)
(+) Does not contribute to tooth cavities
(±) Raises blood sugar (but less than ‘regular’ sugar)
(–) Bloating and diarrhea

• Example: Haribo Sugar-Free Gummy Bears

Question 12

Weekly Physical Activity for Adults

Answer 12

150 minutes of moderate aerobic activity OR
75 minutes of vigorous aerobic activity
PLUS
Muscle-strengthening exercises 2+ days/week

start low go slow

Question 13

Activity Classification

Answer 13

Moderate Aerobic
- Fast walking, water aerobics, biking on flat ground, doubles tennis, mowing the lawn

Vigorous Aerobic
- Jogging/Running, swimming laps, biking fast/on hills, singles tennis, basketball

Muscle strengthening
- Lifting weights, resistance bands, body weight exercises, heavy gardening, yoga

Question 14

Behavioral Therapy

Answer 14

• Individual or group, counselor or alone

• Environmental
- Remove access to high-calorie foods

• Modify Thinking
- Set reasonable short-term goals

• Self-Efficacy
- Optimistic, positive approach

• Social Support
- Family, friends, healthcare providers

Question 15

When to use medication?

Answer 15

• BMI ≥ 30
• BMI ≥ 27 with concomitant diseases/risk factors
- Diabetes, hypertension, dyslipidemia
• Used as adjunct to diet and physical activity
• Used at lowest effective dose
- Minimize adverse events

Question 16

Orlistat (only Alli on dosing list)

Answer 16

• MOA: Blocks gastric and pancreatic lipases
- Prevents breakdown and absorption of dietary fats
• ↓ Weight (5-10 pounds in 6 months), LDL, BP

Xenical (Rx)

• Criteria: >= 12, BMI => 30, or BMI => 27 with risk factors
• Dose: 120 mg PO TID with meals
• Efficacy: decrease fat abs. by 30%

Alli (Non-Rx)

• Criteria: >= 18, ‘for overweight adults’, BMI => 25
• Dose: 60 mg PO TID with meals
• Efficacy: none

Question 17

Orlistat Risks (AE, Avoid In, Contra)

Answer 17

• Adverse Events

• Headache
• GI (flatulence, oily spotting, loose stools, fatty stools, fecal urgency)
• Severe liver injury

AVOID IN
– Thyroid disease
– Cholelithiasis
– Nephrolithiasis 
– Pancreatitis
– Pregnancy

CONTRA:
– Malabsorption syndrome
– Cholestasis

Question 18

Orlistat Counseling

Answer 18

• Supplement to lifestyle modification
- Helpful in initial weight loss and maintenance

• More carbohydrates, less fat

• Helps reduce unwanted GI side effects
• Don’t need to take if eating a fat-free meal

• Recommend taking with multivitamin
- ↓ absorption of fat-soluble vitamins (A, D, E, K)

• Drug interactions due to decreased absorption
- ↓ cyclosporine, levothyroxine, ↑ warfarin effects

Question 19

Counseling Points

Answer 19

• Obesity results from numerous environmental and genetic factors
• Obesity results in many complications including cardiovascular disease, diabetes, and cancer
• Realistic weight loss goal is 10% in 6 months
• Diet and exercise are key to success
• Orlistat is the only FDA approved OTC weight loss medication
• Dietary supplements have not been proven to be effective and may cause several side effects
• GOAL: Achieve healthy weight and maintain it over the long term