Weight loss Flashcards
Weight loss:
Approach to loss?
Approach
*Understand the weight history
-Manage weight as early as possible
-Manage weight expectation (what is realistic and will improve health - typically 10% or more)
-If medication is chosen then tailor to co-morbidities and sustainability of administration
*average standard approach weight loss of 3-4kg after 3 years which typically returns after 6 -24months
Indications for non lifestyle treatments:
BMI >27 = medications
BMI >40 = surgery (or 35 with complications that can improve with weight loss, or 30 with uncontrolled Diabetes or increased CVD risk)
*international guidelines are now recommending surge with BMI over 35 even if no complications or high risk)
Tips:
-Reinforce behaviours
“Im proud of you”
“lots of options’,
“I have your back”,
“my door is always open”
-language choices
“responder to treatment/did not respond to treatment”
-Male specific - catch them at critical times in life, use culturally specific humour
-Children/adolescent:
-use growth charts
-if waist:height (>0.5 = increased cardiometabolic risk)
-be empathetic and demonstrate no stigma
-involve supports (ideally separate consult) to get on the same page to standardise approach to weight loss and language used
(prohealthykids.nsw.gov.au)
-educate about risk of weight gain after weight loss; if >3kg then get review
Food intake guide for women (x2 if a male)
-palm of protein
-thumb of fats
-cup of carbohydrates
-fist of vegetables
*Physiological response to weight loss
-increased hunger signalling (elevations in ghrelin, GLP1, reductions in CCK, leptin and PYY)
-reduced energy expenditure (metabolism adapts to prevent weight loss)
- A previously obese person requires 300-400 calories fewer per day to maintain a normal body weight then a constantly normal body weight person)*
Weight loss:
Medication options?
Glucagon like peptide 1 receptor agonists (GLP1) $300-400/month
-Liraglutide (Saxenda) 3mg daily injection
-Semaglutide (Ozempic) 2.4mg weekly injection
mean weight loss of 8 - 16%
slow gastric emptying, satiate, reduce hunger and food reward
stop after 12 weeks if at max dose and less than 5% lost
Adverse effects:
-nausea/vomiting
-constipation/diarrhoea
-risk of cholelithiasis/cystitis
-pancreatitis
Phentermine $100-150/month
15-40mg daily
noradrenaline, dopamine and serotonin release
Reducing hunger and food reward
typically weight loss of 5-10%
Adverse effects:
-tachycardia/hypertension
-insomnia
-dry mouth
*do not combine with MOAi, SSRIs
Naltrexone/Buproprion (Contrave) $240/month
8/90mg - 16/180mg daily- twice daily
Reduce reward, hunger and food cravings
mean weight loss of 6%
stop after 16 weeks if less than 5% lost
Adverse effects:
-nausea
-dizziness
-headache
-insomnia
-dry mouth
*do not use if seizures, opioid use, consider medication interactions (CYP2D6)
Orlistat $93/month
120mg TDS with meals
Reduces GIT fat absorption by inhibiting gastric and pancreatic lipases
*also lowers LDL (28% when compared to lifestyle changes)
5% weight loss in 1 year
*do not use in cholestasis
Adverse effects:
-steatorrhoea
-flatulence
-fat soluble vitamin deficiency (should be taken with a multivitamin)
Topiramate $11/month
max 50mg BD
unknown weight loss mechanism
5% weight loss after 1 year
Also treats
-epilepsy
-migraine prevention
Adverse effects:
-GIT disturbances
-concentration difficulty/memory impairment
-paraesthesia/taste disturbance
-depression
-closed angle glaucoma
-teratogenic
-renal stones
Tirzepatiude
-dual GLP1 and glucose dependent insulinotropic polypeptide receptor agonist
-TGA approved for DM2 but not available yet
-mean weight loss up to 20%
Weight loss:
Surgical options?
Surgery:
-Roux-en-Y gastric bypass (RYGB) = 25% weight loss at 5 years
-sleeve gastrectomy = 19% weight loss at 5 years
post surgery life long nutritional supplementation and monitoring is required
Typical supplementation
-multivitamin
-calcium/vitamin D
-Vitamin B12 injection 3-6 months
-iron
Monitoring post significant weight loss:
-iron studies
-B12/folate (B12 should be >400)
-Vitamin A, D, E, K (D >75)
-Cu, Zn, Selenium
-FBE
-ECU/LFTs/CMP
-TSH
-lipids
-B1, B6
-PTH
-crosslaps
Bone density - 2 years post surgery
Post operative RED FLAGS
-dysphagia/food intolerance
-abdominal pain
-uncontrolled reflux or nocturnal symptoms
-frequent vomiting
-rapid weight loss
-excessive diarrhoea
-gallstones
-LFT derrangement
-waist circumference is important!!! (men <94cm, women <80cm)
Weight loss:
For fertility?
5-10% in less than 6 months can improve fertility
if has PCOS and obese than 5 -15% should be the aim
Weight loss:
Pregnancy weight gain?
Expected weight gains based on BMI:
<25 11 - 16kg
25 - 30 7 - 11kg
>30 5 - 9kg
