Weight Management

• Factors Influencing Body Weight

  • Non-modifiable factors: Genetic factors, Developmental determinants, Gender, Age
  • Modifiable factors: Physical activity, Diet, Environmental and social factors
• Complexity of Obesity: Many factors affect obesity, Challenge to practitioners and those trying to lose weight, The % of individuals who lose weight and successfully maintain the loss around 1 to 3 %

  
• Obesity

  A disease of the brain, Not just a cosmetic concern, The brain controls what we eat and how much we eat

  
• Hypothalamus

  Regulate appetite and metabolism
• Satiety centre

  Control sensation of hunger
• Hormonal link to obesity: Obesity leads to changes in hormones, Hormonal changes lead to obesity, Disturbed sleep cycle can imbalance the hormones

  
• Clinical Evaluation - History

  • History of present illness (HPI), Past medical history (PMH), Past surgical history (PSH), Social history, Family history, Drug history
• Medications associated with weight gain: Antipsychotics, Antidepressant/anxiolytics, Mood stabilizers, Anticonvulsants, Sleep aids, Diabetes medications, Contraceptives, Antihypertensives
• Clinical Evaluation - Physical Examination

  • Cut off BMI values (Malaysian CPG): pre-obesity (overweight) -23 kg/m2, obesity - >27.5 kg/m2
  • Measures of obesity: BMI 25-29.9 (Grade 1, overweight), BMI 30-39.9 (Grade 2, obese), BMI >40 (Grade 3, morbidly obese)
  • Waist circumference: Waist > 90 cm in men, Waist > 80 cm in women
  • Screening with BMI and waist circumference (WC) measurements should be done yearly
  • BMI has limitations, Mid section weight better proxy

  
• Clinical Evaluation

  • Assess for associated conditions, co-occurring medical conditions and current treatments that could cause obesity
  • Blood Ixs: fasting glucose, lipid profile
  • Examine for hyperlipidemia signs
  • Screen and evaluate for psychiatric illnesses like depression, binge eating and other eating disorders, and mood disorders
  • Manage associated comorbidities to reduce health risk factors
  • Assess for personal habits and barriers to weight loss
  • Counsel the patient and evaluate readiness for weight loss

  
• Weight Management

  Chronic disease that requires lifelong management
• Weight Management Interventions

  • Diet
  • Exercise
  • Behaviour treatment
  • Pharmacotherapy
  • Surgery
• Diet and exercise is the 1st line intervention
• Diet - what to eat

  • Nutritionally balanced, hypocaloric diet: Daily caloric deficit of 500 kcal, Women 1200-1500 kcal/d, Men 1500-1800 kcal/d
  • Unbalanced, hypocaloric diet: High protein, low CHO diets, Low-fat diets
  • Very-low-calorie diets: 500-800 kcal/d, Meal replacement, eg. shakes, short term, medical supervision
• Intermittent fasting (IF)

  Means you don't eat for a period of time each day or week, Restricting calorie intake for an extended period of time
• Physical Activity

  To support an energy deficit, To preserve lean muscle mass, The combination of diet and exercise results in greater weight loss than either modality alone
• Exercise to lose weight

  • Moderate intensity exercises initially for 30 min 3 to 5 times/week, Increase to >60 min on most days of the week, Combine cardio and resistance training for maximum weight loss, RT preserves lean muscle mass in weight loss and increase BMR
• Behaviour Modifications

  • Enhancing communication and avoiding stigmatising, Psychoeducation, Motivational interviewing and behavioural strategies, Psychological interventions
• Behaviour Change

  • Communication and avoid stigmatisation, Psychoeducation: Set realistic goals, short and long term, Motivational interviewing and behavioural strategies: Engagement, Focus, Evoke, Plan, Behavioural strategies: Goal setting (SMART), Self monitoring, Stimulus control, Problem solving, Relapse prevention and management, Psychological interventions
• Pharmacotherapy

  For patients who failed to achieve significant weight loss with diet and exercise, BMI ≥ 30 kg/m2 or BMI ≥ 27 kg/m2 with comorbidities, No response with a >5% weight loss after 3 months or safety/tolerability issues, discontinued and consider alternative medications or treatment, Lifelong Rx, Expect heterogeneity in weight loss response, Not a substitute for diet and exercise, No CI to drug therapies, Weight loss with AOMs is modest, Weight loss not maintained after stop Rx
• Orlistat

  Approved for long-term use, Intestinal lipase inhibitor / Reduces fat absorption by up to 30%, S/E: fatty/oily stool, fecal urgency, oily spotting, increased defecation, fecal incontinence, flatus with discharge and oily evacuation (warn patient)
• Phentermine

  Approved for short-term use (not more than 3 months), Sympathomimetic / Suppresses appetite, S/E: Elevation in BP and PR, insomnia, constipation, dry mouth, difficulty sleeping, irritability, CI: uncontrolled HPT, CVD, hyperthyroidism, glaucoma, breastfeeding
• Phentermine Topiramate

  Topiramate - anticonvulsant, Increase energy expenditure and reduce caloric intake, S/E: Dry mouth, constipation, paresthesia, Severe hypohidrosis and hyperthermia, Increase heart rate, Mood disorders eg anxiety, depression, insomnia, Acute myopia and angle-closure glaucoma
• Naltrexone Bupoprion (Contrave)

  Naltrexone 8mg - opioid receptor antagonist, affects areas of the brain that regulate appetite, reduce eating, Bupoprion 90mg - dopamine and norepinephrine reuptake inhibitor - antidepressant and smoking cessation, blocks rewarding effects of food, Contrave controls cravings and hunger, S/E: Nausea, Vomiting, Dizziness, Dry mouth, Elevation of BP and HR
• High dose Liraglutide 3mg

  GLP-1 receptor agonist / Decreases appetite, increases fullness, increases satiety, S/E: nausea, vomiting and abdominal pain, diarrhoea, constipation
• High dose Semaglutide

  Wegovy, Ozempic, Rybelsus, Semaglutide injection is 2x as effective as Liraglutide in blood glucose control and weight loss
• Wegovy vs Ozempic

  • Wegovy: Superior for weight loss compared to Ozempic, Ozempic: Used for blood sugar level management in adults with Type 2 diabetes
• Oral Semaglutide (Rybelsus)

  Dosage for weight loss: High dose 50 mg, Dosage for glycemic control
• Other drugs that favour weight loss

  • Metformin SR: Reduce gluconeogenesis and increasing peripheral insulin sensitivity, S/E: stomachache, nausea, vomiting, diarrhoea
  • Dapagliflozin (Forxiga): Prevent kidneys from reabsorbing glucose back into the blood, C/I: renal impairment, S/E: increased urination, genital fungal infection, UTI, bone fractures, hypotension
• Surgical Interventions

  Well-established Rx option for morbidly obese and failed medical therapy, Performed laparoscopically, Excellent weight outcomes, Savings over time (reduced co-morbidities), Indications: Morbid obese without comorbidities (BMI > 37.5), Morbid obese with metabolic syndrome (BMI>32.5), Cons: Post-op complications, Costly readmissions, High cost
• Types of Weight loss surgeries (Bariatric Surgery)

  • Restrictive surgeries: Gastric banding, Sleeve gastrectomy
  • Malabsorptive/Restrictive surgery: Gastric bypass
• Antiobesity Devices

  Emerging options, Minimally invasive, Reversible, Potentially more effective than AOMs, Safer and less expensive than surgery
• Intragastric Balloon

  Short term weight management, Alternative to surgery, Can be combined with pharmacological agents eg GLP-1, 6-15% of total body weight loss compared with the 1-5% produced through lifestyle interventions alone, Space-occupying device in stomach, Experience of fullness and satiety, Reduces food intake