women>35in (88cm)

  women<50mg/dl

- Smoking

- Men >45 y/o, women 55y/o or post-menopausal

- 3500kcal = 1 lb of fat, if intake > output by 2% for one year, means 5 lbs weight gain

- Average american gains 20 lbs between ages 25-55, means greater intake of 0.3%/day

- Family history of premature CHD

What are the general principles for weight management therapy in at-risk individuals? 

BMI >25-30 w/ comorbids or BMI >30 --> Lifestyle, Diet, CBT

BMI >27 with co-morbidities or BMI >30 --> Medications

BMI >35 with comorbids or BMI >40 --> Surgery

- Self-monitoring

- Stress-management

- Stimulus control

- Problem solving

- Contigency management

- Cognitive restructuring

- Social support

What are the lifestyle recommendations by the NHLBI?

Diet - 500-1000kcal deficit for loss of 1-2 lbs per week

Physical Activity - Moderate activity for 60 minutes, 3-5x per week to start, increasing to > 60min most or all days of the week

- Motivate the patient, encourage diary keeping, log food intake and exercise, make a commitment

- CNS stimulant, stimulates NE release

- Short term use, <12 weeks

- Most commonly prescribed, least expensive

- Often combined with other agents

- 400,000 Rx's in 2002

- Approved for long term use

- For goal weight loss of 4 lbs or less in first month

- CI in pregnancy and breast feeding

- Increases satiety, quels cravings

- Not recommende for people with BP, CHD, angina, MI, CHF, stroke, TIA, narrow angle glaucoma, seizures

- Comes in 5,10, or 15mg capsules, starting dose 10mg w or w/o food

- Intx with MAOI's, SSRI's, phentermine, TCA's, alcohol, ketoconazole, erythromycin, St. John's Wort, ephedrine, caffeine

- ADR's are dry mouth, constipation, insomnia (duh)

- Gastric and pancreatic lipase inhibitor

- Inhibits 30% of dietary fat, ~300kcal/day

- <1% systemic absorption

- Metabolized to 2 inactive metabolites

- Little if any drug intx

- Xenical 120mg with food, during or 1hr after meal

- Alli would be 60mg dose, same administration

- Patient should be enrolled in Xenicare for support, dietary regiment should contain only ~30% kcal from fat.

- With diet support, side effects are minimal, without diet support, flatulence, greasy stool, spotting occurs much more frequently

- Weight loss 1-2 lbs per week, take fat soluble vitamins (DEK) 2 hours before or after Orlistat

Sibutramine - Patient must have strong appetite, does not feel full, thinks about food a lot, no CV risk, younger

Orlistat - Patient will not feel hungry, has a CV risk, is older, eats out often, on concurrent meds

- Slow release is Wellbutrin or Zyban

- FDA approved for smoking cessation and depression

 - Aminoketone antidepressant

- Minimal effect on norepinephrine and 5HT reuptake, most effect in blocking dopamine reuptake

- Unusual among antidepressants in being weight neutral or causing weight loss

- Candidate for obesity management since depression is common among overweight individuals

- May enhance weight loss when used concurrently with a calorie restricted diet

- Doses of 300-400mg, tapered from 150mg over three days, patient was on a 600kcal/day balanced deficient diet.

- 7.2% weight loss on lower dose, 10.1% on higher dose

- ADR's include seizures, agitation, insomnia, hallucinations, psychosis, etc.

- CI's are eating disorders (restrictive), and seizure disorders

- Drug Intx --> don't use within 14 days of an MAOI

- Serotonin 2c agonist (Lorcaserin 10mg bid)

- Bupropion 400mg + Naltrexone 32mg (Contrave)

- Topiramate 92mg + Phentermine 15mg (Qnexa)

- Diabetic meds

- Psychiatric meds (Olanzapine, Clozapine, Risperidone, TCA's, Lithium)

- Steroids

- Hormones

- Others (Propranolol, Alpha-blockers, Antihistamines)

- Reserved for class III patients, > 100 lbs overweight

- Weight loss is >65% of excess after one year and >50% of excess after 14 years

- 0.5-1% mortality

- 10% complication rate (wound infection, strictures, stomal ulcers)

- Rarely produces malnutrition if pt. remains in follow-up

Monitoring:  AMC requires >10% weight loss prior to surgery, patient info regarding pre,peri, post operation.  Pt. must take B12, MVI, Calcium, Iron, and Zinc.  If gallbladder not removed Ursodiol must be dispensed.  H2RA's for prophylaxis

- Laparoscopic adjustible gastric banding puts silicone band around upper stomach to create small pouch.  Size of pouch can be changed by injecting more saline into port.  Shorter stays, fewer complications, less weight loss (36-38% of excess), stricter diet compliance needed