Module 4: Weight Management
Android Adiposity
-"Apple shaped" -Males --> androgens -Increase lipoprotein lipase in abdomen -Highest association with health risks (CVD)
gynoid adiposity
-"Pear shaped" -Subcutaneous fat in thighs and hips -Females --> estrogen -Increase LPL action in gluteofemoral area -Hardest location for fat loss
AACE/ACE Guidelines on Weight Loss Goals in Adults
-10% to treat diabetes risk (prediabetes and MetS) -To treat T2DM/hypertension: 5-15% weight loss -Dyslipidemia: 5-10% weight loss
Further Evaluation Recommended (cutoff measure) & Referral for Intervention Recommended in pediatric weight assessment (AAP/Endocrine Society)
-2+ years old -Further evaluation: >/= 85th% -Referral for intervention: >/= 85th % BMI-for-age if no pathological cause
AAP Guidelines on weight loss goals in pediatrics
-2-5 years old w/ obesity: no more than l lb/month weight loss -Older children and adolescents: no more than 2 lbs/week
Physical activity recommendations for weight loss
-30 minutes moderate-intensity aerobic activity most days of week (150 min/week) -or 75 minutes per week vigorous-intensity aerobic activity
Further Evaluation Recommended (cutoff measure) & Referral for Intervention Recommended in pediatric weight assessment (USPSTF)
-6+ years old -Further evaluation: >/= 95th% -Referral for intervention: >/= 95th% BMI-for-age
Pediatric BMI Classifications
-< 5th%: underweight -5th%-85th%: healthy -85th%-94th%: overweight ->/= 95th%: obesity -120th% of the 95th%: severe obesity
Adult BMI and Comorbid Risk
-<18.5: underweight (low risk but other problems) -18.5-24.9: healthy (average risk) -25.0-29.9: overweight (increased risk) -30.0-34.9: obesity class I (moderate risk) -35.0-39.9: obesity class II (severe risk) -40+: extreme obesity (very severe risk)
Comprehensive Lifestyle Intervention Program
->/= 6 month program that assists patients with a reduced kcal diet and increase PA through behavioral strategies -On-site, high intensity program (>/= 14 sessions in 6 months) provided by trained interventionist -Face-to-face sessions more effective than electronic
Leptin
-A hormone produced by adipose (fat) cells -Regulates energy balance/suppresses appetite -Levels decrease during weight loss
Peptide YY
-A hormone produced in the small intestine that reduces hunger -Levels decreased in obesity
Cholecystokinin (CCK)
-A hormone secreted by the small intestine (duodenum) in response to the presence of fats. -Promotes release of bile from the gallbladder and pancreatic juice from the pancreas,and reduces stomach motility. -Levels decrease during dieting and weight loss
Screening recommendation (frequency): AACE/ACE, AND, AHA/ACC/TOS, USPSTF
-AACE/ACE: annually -AND: annually -AHA/ACC/TOS: annually -USPSTF: none
Further Evaluation Recommendation (cutoff measure): AACE/ACE, AND, AHA/ACC/TOS, USPSTF
-All except USPSTF: BMI >/= 25.0 -USPSTF: BMI >30.0
Role of TCA's in contributing to overweight/obesity (Amitriptyline/imipramine and Nortriptyline/desipramine)
-Amitriptyline/imipramine: greatest effect on weight gain -Nortriptyline/desipramine: smallest effect on weight gain
Drugs to use with depression
-Avoid lorcaserin with SSRI or SNRI -Use phentermine/topiramate or orlistat
Medical clearance requirements for surgical weight management: women's health
-Avoid pregnancy 12 mo preop and 18 mo postop -Discontinue estrogens -LAGB band adjustments necessary in pregnant women -Monitor nutrition in pregnant women after bariatric surgery
Acid-base disorder: management
-Bicarbonate orally or intravenously; adjust acetate concentration in PN -Salt and volume loading (enteral or parenteral)
Important medical tests in weight management assessment
-Blood pressure -Stress test carotid US CACS -Liver US and/or biopsy -PSG (sleep study)
Medical clearance requirements for surgical weight management: pulmonary
-Chest radiograph before surgery -Quit smoking >/= 6 weeks prior and during postop
Secondary hyperparathyroidism: management
-DXA, serum intact PTH level, 25-hydroxyvitamin D levels -Calcium and vit D supplements
Effect of 3-5% initial body weight loss in adults
-Decrease TG, BG, risk of T2DM
Restrictive surgical procedures for weight management
-Decreases amount of food entering GI tract -LAGB, VSG, intragastric balloons
Restrictive and malabsorptive surgery for weight management
-Decreases amount of food entering GI tract and nutrient absorption -RYBG
Evidence supported meal plan interventions for weight loss
-Decreasing sugar sweetened beverages, portion control, low calorie diet, meal replacement/structured meal plans -Very low calorie diet, low CHO, high PRO with energy restriction, DASH with energy restriction, Mediterranean with energy restriction
Factors of client history
-Demographics -Social history -Medical/health history
Gastric Balloon: expected weight loss
-Excess wt loss: 30-50% after 6 months, 17% after 7 years -Total weight loss: 10% after 6 months, 9kg after 5 years
Criteria for Pharmacotherapy Interventions for Weight Management
-FDA criteria for use: BMI >30 or BMI >27 + 1 comorbidity (HTN, T2DM, Dyslipidemia, OSA) -Use in combination with lifestyle interventions -Continue treatment with weight loss >5% at 3 months, discontinue treatment if weight loss is <5% at 3 months -Can use for up to 2 years
Iron deficiency: management
-Ferrous fumarate, sulfate, gluconate -150-300 mg elemental iron daily -Supplement vit C and folic acid
Methods to prevent weight stigma and bias
-Focus on behavior change rather than weight loss -Do not judge -Use small, realistic goals
Laparoscopic Sleeve Gastrectomy (LSG): Gi anatomy, effect on weight management, effect on metabolism and nutrition status
-GI anatomy: excision of lateral aspect of stomach to create smaller gastric tube -Effect on wt management: limits food intake, increases GLP-1 and PYY, decreases ghrelin -Effect on nutrition status: daily multivitamin w/ mineral preparation, iron, vitamin B12, and calcium w/ vit D taken to reduce possibility of deficiency
Biliopancreatic diversion (BPD): GI anatomy, effect on wt management, effect on nutrition status
-GI anatomy: sleeve gastrectomy with intestinal bypass of all but 100-150 cm of distal ileum -Effect on wt management: limits digestion and absorption to 50-100 cm of SI -Effect on nutrition status: induces extensive nutrient and caloric malabsorption (daily multivitamin, iron, B12, calcium w/ vit D, fat-soluble vitamins)
Roux-en-Y Gastric Bypass (RGB): GI anatomy, effect on weight management, effect on nutrition status
-GI anatomy: stomach transected to create proximal gastric pouch which bypasses remainder of stomach -Effect on wt management: limits food intake, increases GLP-1 and PPYm decreases ghrelin -Effect on nutrition status: induces micronutrient malabsorption (daily multivitamin, iron, B12, calcium with vit D needed)
Laparoscopic adjustable gastric band procedure (LABG): GI anatomy, effect on weight management, expected weight loss
-GI anatomy: use adjustable band to create upper gastric pouch of 15-45 mL and restrict inlet to stomach -Effect on wt management: produce early satiety and limit food intake -Expected wt loss: 14-60% after 7-10 years -Daily multivitamin plus calcium with vit D
Drugs to use for T2SM
-GLP-1 analogs -SGLT-2 inhibitors -With metformin for weight management with BG control
Gastric Balloon: mechanism of action
-Gas or fluid-filled silicone balloons that occupy space in stomach -Max treatment duration: 6 months
CVD Drugs: Lorcaserin (generic name, mechanism of action, key contradictions)
-Generic name: Belviq -MOA: serotonin receptor antagonist -Key contradictions: pregnancy/breastfeeding, serotonin syndrome or neuroleptic
CVD Drugs: Orlistat (generic name, mechanism of action, key contradictions)
-Generic name: Xenical, Alli -MOA: lipase inhibitor -Key contradictions: pregnancy/breastfeeding, chronic malabsorption syndrome, cholestasis, oxalate nephrolithiasis
Depression drug: Naltrexone ER/Bupropion ER (generic name, mechanism of action, key contradictions)
-Generic name: contrive -MOA: opiate antagonist, reuptake inhibitor of DA and NE -Key contradictions: pregnancy/breastfeeding, uncontrolled hypertension, seizure, anorexia, bulimia, severe depression, drug or alcohol withdrawal, concomitant MAOI, chronic opioid use
Depression drug: Phentermine/Topiramate ER (generic name, mechanism of action, key contradictions)
-Generic name: osymia -MOA: NE-releasing agent, GABA receptor -Key contradictions: pregnancy/breastfeeding, hyperthyroidism, glaucoma, concomitant MAOI use
T2DM drug: Liraglutide (generic name, mechanism of action, key contradictions)
-Generic name: saxenda -MOA: GLP-1 analog, scale obesity and prediabetes -Key contradictions: pregnancy/breastfeeding, personal or family hx for medullary thyroid cancer of MEN2, pancreatitis, acute gallbladder disease
Important Anthropometric assessments in weight management assessment
-Height -Current weight and BMI -Weight history -Waist circumference
Important biochemical assessments in weight management assessment
-Hemoglobin A1c -Lipid panel -LFT's (AST/ALT) -Hormones
Nutrition Recommendations and Requirements Post-Surgical Weight Management
-High PRO, low CHO, low fat -Protein: 60-80 g/day -Meals: 4-6/day, 2-4 oz -Avoid energy dense and liquid consistency foods -Sugar-free condiments only -Stop drinking 15 min before a meal until 30 min after meal -Fluid intake: 80 fl oz/d
Skin nutrition-focused physical findings in weight management assessment & possible indications
-Hirsutism (Endocrinopathy- PCOS) -Acne (Endocrinopathy- PCOS) -Acanthosis Nigricans (insulin resistance)
Insulin
-Hormone produced by the pancreas following CHO ingestion -Regulates energy balance, signal satiety to the brain -Resistance in obese persons -Reduced insulin levels after dieting
Complications of obesity and overweight
-Impairs normal physiologic function -Displays characteristic signs or symptoms -Causes harm or morbidity -Costly
Effect of 5-10% initial body weight loss in adults
-Improve lipid profile -Decrease CVD/T2SM meds
Genetic/epigenetic role in obesity/overweight
-Increased food intake -Increased adiposity
Physiologic role in overweight/obesity
-Increased intake: disordered eating, emotional coping -Intake and expenditure: self-regulatory and coping deficits, trauma history, mood disturbance, mental disabilities -Decreased expenditure: social anxiety
Hormonal regulating surgery for weight management
-Increases satiety and decreases hunger via alteration of GI hormones and neuropeptides -VSG, RYGB
Calculating energy needs in adults with overweight/obesity
-Indirect calorimetry or Mifflin-St. Jeor -Multiply RMR by PA factor
Corticosteroid in contributing to overweight/obesity
-Indirectly promote weight gain by stimulating appetite -Increase adipose fat tissue deposits
Sociocultural role in overweight/obesity
-Intake and expenditure: family conflict, social networks, entering into a romantic relationship, lack of employer preparedness to assist with obesity, weight bias and stigma, lack of health care provider support/knowledge, inadequate access to healthcare
Behavioral role in overweight/obesity
-Intake and expenditure: increased availability of energy dense nutrient poor foods and beverages, larger portion sizes, eating as recreation, snacking, special occasions, lack of nutrition education, skipping meals, food insecurity, diet patterns, eating away from home, lack of family meals
Components of lifestyle therapy for adult weight management
-Meal plan/nutrition -Physical activity -Behavior change -Pharmacotherapy and/or surgery
Waist Circumference values in most adults consistent with abdominal obesity and higher metabolic risk
-Men: >/= 94 cm -Women: >/= 80 cm
Medical clearance requirements for surgical weight management: nutritional
-Micronutrients should be measured in all patients prior to surgery -Malabsorptive bariatric procedures require extensive preoperative nutritional evaluations
Head and neck nutrition-focused physical findings in weight management assessment & possible indications
-Moon face (Cushing's) -Prominent dorsocervical fat pad (Chushing's) -Prominent subclavicular fat pad (Cushing's) -Thyroid nodule/enlarged thyroid (Thyroid) All indicate endocrinopathy types
Hormones that stimulate hunger
-Neuropeptide Y -Ghrelin
Environmental role in overweight/obesity
-Pressures on physical activity -Decreased expenditure: consistent temperature, increased sedentary time, built environment, decreased opportunity for non-exercise based physical activity, labor saving devices
Medical clearance requirements for surgical weight management: psychosocial
-Psychosocial evaluation to assess psychiatric, environmental, familial and behavioral factors -Ability to incorporate nutritional and behavioral changes after surgery should be assessed
Meal plan principles for adult weight management interventions
-Reduced calorie healthy meal plan -~500-750 kcal daily deficit -Individualize based on personal and cultural preferences -Mediterranean, DASH, low-carb, low-fat, volumetric, high PRO, vegetarian
GIP hormone
-Released from duodenum, jejunum -Energy storage -Levels increase during dieting and weight loss
GLP-1
-Released from the ileum of the SI -Suppresses appetite and increase satiety -Decreased functionality
Ghrelin
-Secreted by empty stomach -Stimulates appetite for high-fat high-sugar foods -Levels increase during dieting and weight loss
Neuropeptide Y
-Secreted by the hypothalamus -Increases food intake and -Decreases physical activity -Increases the proportion of energy stored as fat -Inhibited by leptin
PA Factors
-Sedentary: 1.00-1.39 -Low active: 1.40-1.59 -Active: 1.60-1.89 -Very active: 1.90-2.49
Gastric Balloon: adverse effects
-Serious AE: device migration, bowl obstruction, perforation -Common AE's: nausea, vomiting, stomach pain in first 72 hours
Brown adipocytes: shape, size, lipid droplets, body location, function
-Shape: polygonal -Size: smaller -Lipid droplets: numerous, small -Body location: neck, shoulders, spine -Function: energy release, regulated by mitochondrial UCP-1
Beige/brite adipocytes: shape, size, lipid droplets, body location, function
-Shape: round -Size: larger -Lipid droplets: intermediate -Body location: subcutaneous, visceral -Function: energy release, regulated by mitochondrial UCP-1
White adipocytes: shape, size, lipid droplets, body location, function
-Shape: round -Size: larger -Lipid droplets: single, large -Body location: subcutaneous, visceral -Function: energy storage
Components of Staged Therapy for Pediatric Weight Management: Stage 1 (where, what, goals)
-Stage 1: prevention plus -Where: primary care office -What: planned follow up themed visits focusing on behaviors that resonate with the patient/family and tailored to their motivation -Goals: positive behavior change regardless of change in BMI
Components of Staged Therapy for Pediatric Weight Management: Stage 2 (where, what, goals)
-Stage 2: structured weight management -Where: primary care office -What: same intervention as stage 1 but more intense support and structure. Follow-up every 2-4 weeks. If no change in BMI after 3-6 months, advance to step 3 -Goals: positive behavior change, weight maintenance or decrease in BMI velocity
Components of Staged Therapy for Pediatric Weight Management: Stage 3 (where, what, goals)
-Stage 3: comprehensive multi-disciplinary intervention -Where: pediatric weight management clinic -What: increased intensity of behavior changes, frequency of visits and specialists involved. Follow up every 2-4 weeks. If no change in BMI after 3-6 months advance to step 4 -Goals: positive behavior change, weight maintenance or decrease in BMI velocity
Components of Staged Therapy for Pediatric Weight Management: Stage 4 (where, what, goals)
-Stage 4: tertiary care -Where: pediatric weight management center -What: children with BMI >95th% and significant comorbidities. Intensive diet and activity counseling with consideration for use of medication/surgery -Goals: positive behavior change, decrease BMI
Abdomen nutrition-focused physical findings in weight management assessment & possible indications
-Striae (endocrinopathy - cushing's) -Hepatomegaly (NAFLD)
Meal plan and behavior-based principles for pediatric weight management interventions
-Structured daily meals and planned snacks w/ no food or calorie containing beverages at other times -Less than 1 hr/day screen time -60 min/day PA -Planned reinforcement for achieving targeted behaviors -Monitor behavior with logs
Relationship between overweight/obesity and risk of chronic diseases (specific)
-T2DM: 3x higher in obese -HBP: 2x more likely with BMI > 30 -Dyslipidemia, CHD -Risk of gallstones and hepatic disorders increases -Cancer and reproductive disorders
Fat-soluble vitamin dependency: management
-Vit A: 5,000-10,000 u/d -Vit D: 400-50,000 ug/d -Vit E: 400 u/d -Vit K: 1 mg/d -ADEK: 2 tables twice per day
Lungs nutrition-focused physical findings in weight management assessment & possible indications
-Wheezes (pulmonary - asthma) -Crackles or rales (pumnonary - CHF) -Tachycardia (CAD) -Murmur (CAD)
Components of a successful and healthful weight management program
1. Focus on improving overall health 2. Require a lifelong commitment 3. Incorporate healthful lifestyle behaviors 4. Include sustainable and enjoyable eating practices 5. Include healthful dietary intake 6. Include daily physical activity
Physical activity recommendations for weight loss maintenance
>250 minutes per week (average 200-300 minutes) moderate-intensity aerobic activity
Atypical Antipsychotics in contributing to overweight/obesity (Clozapine)
Clozapine may increase appetite
Osteoporosis: management
DXA, calcium, vit D, biphosphates
Meal plan interventions lacking evidence for weight loss
Decreasing fast food, energy density diet, eating frequency, breakfast consumption, timing of eating
Role of resistance exercise in weight loss
Resistance exercise alone or in combination with aerobic exercise does not strongly support weight loss/maintenance
Thiamine deficiency (B1): management
Thiamine intravenously followed by large-dose thiamine orally
Bacterial overgrowth (BPD): management
Antibiotics (metroidazole, probiotics)
Diagnosis Recommendation (defining excess adiposity in clinical setting)
All: -BMI >/= 25.0 (overweight) -BMI >/= 30.0 (obese)
Principles of Chronic Care Model for pediatric weight management
Family and patient self-management (community resources, and healthcare) -Environment: family, school, worksite, community -Medical system: information systems, decision support, delivery system design, self-management support
Folic acid deficiency: management
Folic acid supplementation
Factors of Food and Nutrition-Related History
Food allergies/intolerances, food preferences, typical food and nutrient intake, typical beverage intake, meal/eating patterns, meal preparation methods, frequency meals outside home, relationship with food, previous food restrictions, previous nutrition education
Evidence considered non-supportive meal plan interventions for weight loss
Increasing fruits and vegetables, low glycemic index without energy restriction
Antihistamines in contributing to overweight/obesity
Indirectly promote weight gain by stimulating appetite
Antineoplastic agents in contributing to overweight/obesity
Indirectly promote weight gain by stimulating appetite
Antidiabetic agents in contributing to overweight/obesity (insulin)
Insulin increases deposition of adipose tissue
Oxalosis: management
Low oxalate diet, potassium citrate, probiotics
B12 deficiency: management
Parenteral B12, methylmalonic acid
Multidisciplinary team approach to pediatric weight management
Patient and family: activity, nutrition, medicine, mental health
Relationship between overweight/obesity and risk of chronic disease
Risk of chronic disease goes up as weight goes up
What populations are at higher risk for abdominal obesity and metabolic problems based on waist circumference
South/Southeast Asians, East Asian Adults -Men: >/= 85 cm -Women: >/= 74-80 cm
Anticonvulsants in contributing to overweight/obesity (Valproic Acid/Carbamazepine)
Valproic acid and carbamazepine may increase appetite
Role of MAOI's in contributing to overweight/obesity
Weight gain less intense than with TCA's
AND Guidelines on Weight Loss Goals in Adults
Weight loss of 3-5% has the ability to produce clinically relevant health improvements (up to 2 lbs/week)
Hormones that stimulate satiety
insulin, leptin, peptide YY, cholecystokinin (CCK), GLP1