Week 2: Overweight and Obesity

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What is the role of ghrelin

triggers the CNS appetite stimulant (NPY), growth hormone, and norepinephrine

Which hormone is predominantly involved in stimulating carbohydrate intake?

Neuropeptide Y

How does weight loss impact serum ghrelin levels?

Increases them

Which group of peptides plays a role in satiety and reduced food intake?

Cholecystokinin, serotonin, peptide YY

What factor may influence nutrient selection during weight loss treatment?

Peptide YY increase during high protein diets

What is one of the major barriers mentioned in the text regarding obesity and its common comorbidities?

Silent nature of obesity and its related health conditions

What is essential to building rapport with obese patients?

Compassion, understanding, and flexible weight loss recommendations

What should be the initial step in the clinical evaluation of an obese patient, as mentioned in the text?

Proper assessment of barriers to and benefits of weight loss

What BMI range do most individuals seeking professional help with weight loss typically fall into?

38 or more

Why is establishing where the patient is located on the Stages of Change Model useful, as mentioned in the text?

To develop a tailored plan for the individual based on their readiness to change

What is a characteristic of most patients who seek medical care for obesity, as per the text?

Only a minority present requesting medical help with weight reduction

What is the impact of obesity on life expectancy according to the text?

Decreases life expectancy by 7 years

What is the second leading cause of preventable death in the USA?

Obesity and sedentary lifestyle

Which behavior change approach is critical for managing obesity according to the text?

Lifestyle changes

What is the foundation of a behavioral-based approach to managing obesity?

Exercise, diet modifications, and lifestyle changes

Which type of fat lies deep within the body cavities and surrounds internal organs such as the liver, pancreas, and intestines?

Visceral fat

What is a practical measure used to assess visceral fat without needing imaging techniques like MRI or CT scans?

Sagittal diameter

Why is visceral fat considered to be more detrimental to health compared to subcutaneous fat?

Due to its metabolic characteristics like insulin resistance and glucose intolerance

What does a sagittal diameter measurement greater than 30cm indicate in relation to health risks?

Increased cardiovascular disease risk and insulin resistance

Which of the following imaging techniques is NOT typically used to measure visceral fat?

DEXA scan

During a sagittal diameter measurement, at what level should the distance be measured from the floor/plinth to the anterior abdomen?

At the level of the iliac crest

Which medical condition is NOT mentioned as a potential cause of obesity?

Hypertension

What aspect of obesity history should be considered when obtaining a patient's history?

Changes in weight distribution

Which of the following is NOT a medication known to potentially increase weight?

Antibiotics

What type of exercise barriers should be evaluated when assessing a patient for exercise opportunities?

Availability of exercise facilities

Which eating disorder is NOT mentioned as part of the history that should be considered in obese patients?

Orthorexia nervosa

Why is it important to establish where the patient is located on the Stages of Change Model in the treatment of obesity?

To help approach and commence the treatment plan

How should readiness to change (i.e., to lose weight) be used in developing a tailored plan for obese patients?

To develop a plan based on the individual's willingness to lose weight

What is the initial step recommended in the clinical evaluation of an obese patient?

Proper assessment of the barriers to, and benefits of, weight loss

Describe the role of ghrelin

it is a potent appetite increasing gut hormone that is produced as the stomach empties, triggering the CNS appetite stimulant NPY, growth hormone, and norepinephrine

Name 3 stimulatory monoamine and peptides that affect appetite

Norepinephrine, nueropeptide Y (NPY), opioids, Melanin (concentrating hormone)

Name 3 Inhibitory monoamine and peptides that affect appetite

Leptin, cholecystokinin, setotonin, corticotropin (releasing hormone)

What are some lifestyle changes you should identify that could present as barriers to weight loss

  1. Smoking cessation (^ in cravings)
  2. Job change 3.Injuries restriciting physical activity 4.poor sleeping habits
  3. Stress --> ^ eating

Why can nutrient selection play a factor in weight loss

Because peptide YY (appetite reducing) is increased during high protein diets

Describe Set point theory

Weight loss decreases TEE and REE which slows further weight loss Weight gain through over feeding is associated with an ^ in energy expenditure, which slows further weight gain

What role does readiness to change (i.e., lose weight) play in developing a tailored plan for obese patients according to the text?

It helps in educating precontemplators

In which model is it suggested to establish where the patient is located to aid in initiating treatment for obesity?

Stages of Change Model

Why might obesity and its common comorbidities present a challenge in clinical assessment according to the text?

They are often silent

How can the Stages of Change Model be useful in guiding the approach to treatment for obese patients?

By tailoring treatment based on patient's readiness to change

What should be established as the initial step during the clinical evaluation of an obese patient?

'Proper assessment of barriers to, and benefits of, weight loss'

What is the primary difference in the effects of aerobic and resistance exercise on visceral fat reduction?

Aerobic exercise reduces visceral fat without weight loss, while resistance exercise does not.

Why is resistance training recommended for individuals in weight loss programs?

To reduce potential losses in lean mass.

Which aspect of weight loss via caloric restriction can lead to undesirable effects on various body parts?

Changes in body composition

How does regular aerobic exercise protect against potential negative effects on muscle and bone strength?

By preventing undesirable weight loss effects

Why is resistance exercise particularly recommended for individuals desiring to lose significant amounts of weight?

To offset potential losses in lean mass

What is a key reason why regular aerobic exercise is beneficial despite weight loss via caloric restriction?

It may protect against negative effects on muscle and bone strength.

What is the primary reason why resistance training is recommended for most weight loss programs?

To offset potential losses in lean mass

How does resistance training help individuals who aim to lose significant amounts of weight?

By maximizing lean mass loss

What is the main advantage of regular aerobic exercise over resistance training when it comes to protecting against negative effects?

It may prevent undesirable weight loss effects on various body parts.

What should obese individuals consider regarding aerobic and resistance exercise based on the given information?

Aerobic exercise is more favorable for reducing visceral fat compared to resistance training regardless of weight changes.

Study Notes

Subcutaneous Adiposity

  • Visceral fat lies deep within the body cavities, surrounding internal organs including the liver, pancreas, and intestines
  • Visceral fat can be stored within the liver and lead to non-alcoholic fatty liver disease (NAFLD)
  • Visceral fat accumulation is associated with a higher cardiometabolic risk than subcutaneous fat due to its metabolic characteristics, which include insulin resistance and glucose intolerance

Visceral vs. Subcutaneous Adiposity

  • Visceral fat is best measured by MRI, U/S, or CT
  • A more practical measure is sagittal diameter
  • Sagittal diameter is the distance from the floor/plinth to a horizontal level at the anterior abdomen at the level of the iliac crest, taken during a normal exhalation (tidal breathing)
  • A sagittal diameter > 30cm is related to an increase in cardiovascular disease risk and insulin resistance

Overweight and Obesity

  • Overweight and obesity are associated with an increased rate of death from all causes, particularly from cardiovascular disease
  • Obesity and sedentary lifestyle are considered the second leading cause of preventable death in the USA and may overtake tobacco abuse within the next decade
  • For obese individuals, life expectancy decreases by about 7 years compared with normal-weight individuals

Overweight and Obesity in Australia

  • In Australia, per capita spending is approximately $830 more for an obese individual versus someone of normal body weight
  • Obesity reduces life expectancy, and this effect is more powerful in those who develop obesity earlier in life

Pathophysiology of Obesity

  • Obesity results from longstanding positive energy balance
  • Average daily calorie intake has increased by over 200 kcal over the last several decades as food costs have fallen dramatically and as more calories are consumed outside the home
  • At the same time, physical activity has fallen because of advances in equipment and ergonomics in the workplace

Clinical Considerations in Overweight and Obesity

  • Medical causes of obesity, including illnesses, medications, and lifestyle changes known to increase weight, should be identified
  • Establishing where the patient is located on the Stages of Change Model can be useful in helping to approach and commence a treatment plan
  • Readiness to change (i.e., to lose weight) should be used to develop a tailored plan for the individual### Pathophysiology of Obesity
  • Obesity results from longstanding positive energy balance.
  • Average daily calorie intake has increased by over 200 kcal over the last several decades due to decreased food costs and increased consumption outside the home.
  • Physical activity has fallen due to advances in equipment and ergonomics in the workplace.
  • Genetic and physiologic factors, including neurological and peripheral endocrine messengers, influence food intake and nutrient utilization, making weight loss efforts challenging.
  • Advanced neuroimaging research has shown similar patterns of brain activation between addictive-like eating and substance abuse.
  • Leptin, secreted by fat cells, is produced in proportion to weight and girth, but exogenous leptin administration has limited benefit for weight reduction.
  • Genetic causes of obesity are rare, but a factor in at least half of human obesity, and body fat distribution is also genetically determined and gender-specific.

Clinical Considerations in Overweight and Obesity

  • Medically significant obesity exists in most patients, but only a minority present requesting medical help with weight reduction.
  • Compassion and understanding, coupled with flexible and practical weight loss recommendations, are essential for building rapport with obese patients.
  • Most individuals seeking professional help with weight loss have a BMI of 38 or more and have attempted to lose weight several times in the past.
  • Proper assessment of the barriers to, and benefits of, weight loss should be the initial step in the clinical evaluation of the obese patient.

Exercise Testing

  • Exercise testing is performed to assess for the presence of coronary artery disease, determine functional capacity, and develop an exercise prescription based on heart rate.
  • Seated devices, such as upper body ergometers, stationary cycles, or recumbent stepping machines, offer alternatives for patients who are unable to perform weight-bearing exercises.
  • A low-level protocol with small increments (e.g., 0.5-1.0 MET) may be preferred for patients with a low peak exercise capacity.

Medical Management Summary

  • A deficit of 7,700 kcal is needed to lose 1kg, so a typical diet can yield about 0.5kg of weight loss per week.
  • Low-fat diets are recommended due to the high calorie content of fat and the heart health benefits for cholesterol lowering.
  • Higher-protein and lower-carbohydrate diets have been favored by patients due to greater weight losses and better satiety.

Surgical Therapy

  • Surgical procedures, such as laparoscopic techniques, can cause patients to lose one-third of their weight (>50% of their excess weight) within 18 months.
  • Research has confirmed improved mortality rates with weight loss surgery, but there are significant risks (up to 1% for death and 15% for morbidity).
  • Patients undergoing bariatric surgery must commit to a lifelong program of restricted diet, lifestyle changes, vitamin supplementation, and follow-up testing to ensure safety.

Exercise Prescription

  • Exercise for weight gain prevention requires 150-200 minutes/week (1,200-2,000 kcal/week).
  • Exercise alone for weight loss requires high amounts of total caloric expenditure, likely in the range of >3,000 kcal/week (225-420 minutes/week).
  • Exercise and caloric reduction for weight loss can increase the weekly rate of weight loss by approximately 1kg over caloric reduction alone.
  • Regular exercise of 60-90 minutes on most days of the week is generally recommended for long-term weight loss maintenance.

Cardiorespiratory Exercise

  • Initially, exercise and physical activity should focus on cardiorespiratory (aerobic) modes, as they are linked to reductions in body mass.
  • Resistance training may provide added benefits, particularly with respect to body composition, but the caloric expenditure of resistance training is less than that of aerobic exercise.

Explore the pathophysiology of obesity with a focus on the reduction of ghrelin hormone in patients after gastric bypass weight loss surgery. Learn about the role of ghrelin in triggering appetite-stimulating hormones like neuropeptide Y and norepinephrine.

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