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Obesity/Nutrition

Liana Mosley

Class BMI
Underweight < 18.5
Normal 18.5 – 24.9
Overweight 25.0 – 29.9
Obese Class I: 30.0 – 34.9
Class II: 35.0 – 39.9
Class III: >40

Background

  • BMI = Body Weight (kg) / Height (meters)2
  • 42% of US adults are obese. 74% of adults are overweight or obese.

Evaluation

  • USPTF: Pts with BMI >30 should be offered or referred to intensive, multicomponent behavioral interventions
  • Screen for co-morbidities: HTN (BP), HLD (lipid panel), DM (A1c), MAFLD (LFTs), OSA (polysomnography), consider TSH if other symptoms of thyroid dysfunction

Management

  • Goals:
    • Target weight loss of 5-7% body weight
    • An average deficit of 500 kcal/day should result in an initial weight loss of ~0.5 kg/week (1 lb/week)
    • Even weight loss of 3-5% produces clinically meaningful health benefits
    • Regaining weight is common, schedule frequent follow up to assess and encourage progress
    • Have pts keep a food log or recall last 24 hrs of food history in clinic
    • Limit high caloric beverages and processed foods first
    • Encourage accountability partners
    • Share MyPlate information
    • Consider weight loss apps: My Fitness Pal, Lose it, Noom
  • Dietary options:
    • Total calorie restriction is the most effective dietary intervention for weight loss
    • Generally, encourage patients to pursue whatever dietary intervention is most sustainable for their lifestyles
    • Mediterranean diet: high in fresh vegetables/fruits, whole grains, legumes, unsaturated fats, moderate diary and EtOH, less meat
    • Associated with decreased overall mortality and CV mortality, may decrease DM incidence independent of weight loss
    • DASH diet: 4-5 servings of fruit, 4-5 servings of vegetables, 2-3 servings of lowfat dairy per day, and <25 percent dietary intake from fat
    • Associated with decreases in SBP and DBP
    • There is mixed evidence for intermittent fasting, low carb, low fat, and high protein diets
  • Exercise: goal >30 min, 5-7 days per week
    • Ideally combination of aerobic and resistance training
    • Exercise alone is not sufficient for weight loss. Associated with maintaining weight loss
  • Pharmacotherapy
    • BMI ≥30 or ≥27 with co-morbidity
    • Leads to significant short term weight loss, high rates of rebound, weight gain
  • Bariatric Surgery:
    • Indicated for patients with BMI >40 or >35 with obesity related co-morbidity and failed lifestyle intervention
    • Referral to Surgical Weight Loss Clinic
  • Medical Weight Loss Clinic:
    • Can refer for patient with BMI >30 or >27 with obesity related co-morbidity
    • VA: Consider referral to MOVE program (in-person or telehealth options)
Medication Mechanism Common Side Effects
Phentermine-topiramate (Qsymia) Phentermine: appetite suppression
Topiramate (anticonvulsant, migraine txt): ?appetite suppression, ?altered satiety perception		 Constipation, dizziness, dry mouth, taste changes, tingling of hands and feet, insomnia
Naltrexone-bupropion (Contrave) Naltrexone (partial opioid antagonist; used for alcohol dependence): ?altered satiety perception
Bupropion (antidepressant): ?altered satiety perception		 Constipation, diarrhea, dizziness, dry mouth, headache, BP, tachycardia, insomnia, liver damage, nausea/vomiting
Phentermine (Ionamin) Reduces appetite
Note: FDA-approved only for short-term use—up to 12 weeks		 Dry mouth, constipation, insomnia, dizziness, nervousness/restlessness, headache, HTN, tachycardia
Addictive
Tirzepatide (Zepbound) GLP-1/GIP Agonist; reduces appetite Nausea, vomiting, diarrhea, abdominal pain, constipation
Semaglutide (SQ:Wegovy)
Liraglutide (SQ:Saxenda)		 GLP-1 receptor agonist; reduces appetite Nausea, vomiting, diarrhea, abdominal pain, constipation

Additional Information

  • EPIC Dot phrases:
    • .NHFOODINSECURITY
    • .NHFOODASIANDIET
    • .NHFOODLATINDIET
    • .NHFOODAFRICANDIET
    • .NHFOODHEALTHYPLATE
    • .NHOBESITYYMCA