Practice Nurse

Weight Management

This CPD resource is designed to assess the individual's knowledge on common issues of weight management relevant to your practice. A basic understanding of weight management is assumed but for those who need more information, our recommended reading list comprehensively covers all material that is relevant and endorsable relating to weight management. Furthermore, on completion of the questions, hyperlinks will take you to further reading materials that will support your learning.

This resource delivers 10 clinical self assessment questions relating to obesity with which the user can identify from typical practice. The resource covers aspects of weight management such as basic anthropometric measurements and management strategies, as well as dietary and lifestyle interventions. Each question is designed to assess the user's knowledge of relevant topics in weight management that would be expected to be generated in day to day practice. Following successful completion of this resource the user should:

Be able to calculate BMI correctly, understand the classification of BMI and the value of waist circumference.

Increase their understanding of the concepts of hypocaloric diets and the calorific contribution of exercising.

Improve their understanding of the role of pharmacotherapy in the management of obesity, its indications and potential side effects, and also the potential role of surgical intervention

Have a greater understanding of the metabolic syndrome.

A basic understanding of weight management is assumed but for those that need more information, our recommended reading list comprehensively covers all material that is relevant and endorsable relating to weight management. Furthermore, on completion of the questions, hyperlinks will take you to further reading materials that will support your learning.

This CPD resource delivers 10 clinically self assessment questions relating to obesity with which the user can identify from typical practice. The resource covers aspects of weight management such as basic anthropometric measurements, management strategies, as well as dietary and lifestyle interventions. Each question is designed to assess the user's knowledge of relevant topics in weight management that would be expected to be generated in day to day practice. Following successful completion of this CPD resource the user should:

Understand the concepts of hypocaloric diets and the calorific contribution of exercising.

Understand the role of pharmacotherapy in the management of obesity, their indications and potential side effects and also the role of potential surgical intervention.

Become familiar with the so-called 'Metabolic Syndrome'.

A 55 year old female attends the surgery as she is concerned about the weight she has gained over the last 5-6 years. She is otherwise healthy and has tried a number of diets in the past, none of which have been particularly successful, having lost a few kilos only to subsequently regain them. She enquires whether there is anything that she could take, in conjunction with lifestyle changes, that might help her to lose weight. Her weight is 102kg, she has a waist circumference of 100cm and her BMI is 35.5 kg/m

In this scenario, the patient is obese ( BMI of 30 or more), who has struggled to lose weight with dietary approaches and is now seeking medical intervention, 

 would recommend a trial with orlistat. Orlistat reduces the absorption of oral fat by approximately 30% hence reducing the absorption of calories derived from oral fat intake. It has been proven in clinical studies to assist with weight loss and has an acceptable safety profile. Both rimonabant and sibutramine have had their marketing licences withdrawn by the MHRA and are no longer available for prescription. Metformin is not associated with weight loss and its not used to reduce weight, even in patients with diabetes.

http://www.nice.org.uk/nicemedia/live/11000/30365/30365.pdf

http://www.netdoctor.co.uk/diet-and-nutrition/medicines/xenical.html

1. What are the side effects of orlistat?

2. When would you consider withdrawing orlistat?

3. What weight loss might an individual expect with the use of orlistat?

Question 1

A 57 year old female attends your weight management service and is keen to seek advice on how to lose weight. Her weight is 90kg and her BMI is calculated as 34.3 kg/m

. She has gained weight over the last four years and she has recently been trying hard to lose weight on a diet. She asserts that she has not been able to lose weight despite sticking to a diet of 1600 kcal per day. She feels at her wits end regarding her inability to lose weight.

You take a detailed dietary history and note that she is eating approximately 1700 kcal of food daily but she also drinks 3 bottles of wine each week.

What is the calorific value of one bottle of wine?

As is often the case, the patient is unaware of the calorific value of alcohol. She is underestimating her daily calories and the contribution of this to her difficulties losing weight. Despite the consumption of a hypocaloric diet with regard to food, this woman consumes at least an extra 1500 kcal per week of wine - this provides at least an extra 200 kcal per day in addition to her normal calorie counting. Depending on alcohol strength as well as sugar content, a bottle of wine contains roughly 

. Thus, it is important to advise correctly that a total calorie intake of 1500 kcal per day will result in a weight loss of approximately 0.5 kg (1lb) per week.

It is also important to be aware here of the number of units of alcohol that this woman is consuming. A bottle of wine contains approximately 9-10 units of alcohol (depending on strength). Therefore this woman drinks 27-30 units of alcohol weekly which is above the 

of 14 units for a female and 21 units for a male. The patient should also be given advice regarding safe drinking.

http://www.nhs.uk/Livewell/alcohol/Pages/Effectsofalcohol.aspx

2. Why do the recommended limits of alcohol differ between males and females?

3. What are the calorific values of other alcoholic drinks such as beers, alcopops and spirits?

Question 2

A 45 year old female attends the surgery seeking advice regarding weight loss. She has gained a ‘few pounds’ over the last 5 years and now weighs 83 kg and has a BMI of 36.8 kg/m

. On further questioning, she informs you that she has tried a number of fad diets without much success and has difficulty understanding the concept of diets.

You provide her with advice regarding lifestyle changes including exercise and diet and explain to her about metabolic rate and dietary calorie restriction. She asks what her total daily energy expenditure (metabolic rate) is.

Which of the following is the correct answer?

Weight loss should be a relatively simple process and it depends on the number of calories going in (dietary consumption) and the number of calories burned (basal metabolic rate). The average total daily energy expenditure (surrogate of metabolic rate) for a female is 2000 kcal/d and it is 2500 kcal/d for a male. One misconception with many obese patients is that their basal metabolic rate is lower than others. This is not the case, as the heavier a person is, the more energy is required for metabolism and exercising. Thus studies confirm that metabolic consumption increases with obesity.

It is important to know what the average total daily energy expenditure is, as if a patients diet has less calories than the total energy expenditure, the patient will lose weight. Thus, maintaining a hypocaloric diet of 1500 kcal/d is usually advised and will result in typical weight loss of approximately 1lb (0.5kg) per week.

However, most patients struggle with maintaining this restrictive diet and it is important to realise that the drugs available result in weight loss either through reducing the actual quantities of calories consumed through reducing appetite (rimonabant), increasing satiety or reducing the calories absorbed from the GI tract (orlistat).

1. What evidence is there suggesting that obese subjects have lower total daily energy expenditure?

2. Why is there a sex difference between basal metabolic rate (BMR)/total energy expenditure (TEE)?

Question 3

A 35 year old female has unsuccessfully tried to lose weight through diet and exercise and has also tried drugs such as orlistat, which she was unable to tolerate. She had also tried sibutramine for a period of approximately three months and found this helpful although the drug was withdrawn.

Her weight is 102.2 kg, her BMI is 45.5 kg/m

 and she has a waist circumference of 110cm. She is rather concerned about her weight problems and enquires if there might be anything else that she could consider to help with weight loss.

This patient is morbidly obese as indicated by a BMI in excess of 40. Current 

 suggest that bariatric surgery – laparoscopic banding or bypass is the primary treatment modality in patients with a BMI above 50 and is recommended in patients with a BMI above 40 (above 35 if associated with co-morbidities such as diabetes and hypertension) in whom diet, exercise and drug therapy have failed. Thus, this patient could be advised to discuss surgical management of her obesity with her GP. There is no evidence that replacing one agent with another weight reducing drug would have any advantage nor is there evidence supporting the combination of sibutramine (license withdrawn) and orlistat.

1. What types of bariatric surgery are there, which is recommended and what does bariatric actually mean?

3. Is bariatric surgery available via the NHS in your locality?

Question 4

A 53 year old female is given a prescription from her GP for orlistat. She has been struggling with weight loss on diet alone for a year or so and feels that she needs some help. Her weight is 88kg and her BMI is 33 kg/m

. She has heard much about orlistat and is keen to try this drug but her only concerns relate to typical side effects associated with this drug.

Which of the following would be a typical side effect relating to orlistat?

 (Xenical) is a GI lipase inhibitor and helps patients to lose weight through reducing the absorption of dietary fat by approximately 30%. Thus, this dietary fat remains in the colon and is excreted in the faeces – hence 

 of orlistat associated with the retention of this extra fat (including GI upset - flatulence, oily discharge from the rectum, diarrhoea and faecal incontinence) are quite common (>5%). Prior to commencing orlistat, patients should be warned about these side effects and the importance of reducing their dietary fat intake. It is the unabsorbed fat that causes the most of these symptoms so meals should contain no more than 30% fat in order to reduce them. This may be a key mechanism through which orlistat helps patients to lose weight - reducing the fat in the diet promotes a healthier diet and a hypocaloric diet, leading to weight loss.

In relation to the other options listed, sibutramine has been withdrawn because of the association with hypertension, and rimonabant was withdrawn due to the psychiatric side effects, particularly depression associated with this agent.

http://www.patient.co.uk/health/Orlistat-Help-With-Weight-Loss.htm

1. What contra-indications are there to the use of orlistat?

2. What are the current indications for orlistat and when should it be withdrawn?

3. What average weight loss can be expected following the use of orlistat?

Question 5

Sibutramine was a popular therapy in the treatment of obesity and was supported by NICE guidance. However, the drug was withdrawn as post-marketing studies revealed an increased risk of which of the following?

Sibutramine was a popular agent used to assist with weight loss. It is a noradrenergic and serotinergic reuptake inhibitor, producing weight loss through increasing satiety – making the patient feel fuller on smaller meals. It was withdrawn due to a recognised risk of myocardial infarction and stroke through post-marketing pharmaco-vigilance.

1. What is the mechanism by which sibutramine may produce a rise in blood pressure?

2. What percentage of patients develop hypertension or other side effects whilst taking sibutramine?

3. What evidence was there of the risk of MI and stroke with sibutramine?

Question 6

A 28 year old female attends the surgery and is concerned about her weight. She has commenced the oral contraceptive 1 year ago and feels that she has gained a 'bit of weight' since then. Her weight is 65 kg and height is 150cm. Which is the most appropriate description for this patient?

BMI is a vitally important measurement in defining the individual's weight in relation to their body habitus. The classification of body weight is based on a number of specific values as this table illustrates:

In this case, the patient's BMI is calculated as:

This would classify this patient as overweight. Appropriate lifestyle advice and dietary advice should be provided to the patient. The oral contraceptive is often associated with weight gain as the high dose of ethinyl-oestradiol may stimulate appetite.

Suggested points for reflection:
1. What is the relationship between BMI and co-morbidities such as hypertension and diabetes?
2. What deficiencies are associated with BMI? Are there better parameters of risk?
3. What is the evidence that BMI is underestimated or even calculated wrongly?

Question 7

A 36 year old female attends your clinic seeking assistance with regard to weight loss. Her BMI is 29.6 kg/m

. She is provided with dietary advice and reducing calorie intake and is also given advice regarding exercise. She is quite keen on having a pedometer to improve her fitness and the amount of walking that she does each day. She understands that she should do 10,000 steps per day with the pedometer and wants to know how many calories this would burn each day?

has proven a very useful device for some people to increase their exercise. The average person walks between 3,000 and 4,000 steps per day, and 1,000 steps is the equivalent of around 10 minutes of brisk walking The pedometer can be worn on the belt and notes each step a person takes. Typically they are advised to perform 10,000 steps per day and this simple exercise process is associated with burning approximately 500 kcal each day. Thus, over a week this calorie burn would reflect a 0.5 kg weight loss.

http://www.nhs.uk/Livewell/loseweight/Pages/10000stepschallenge.aspx

1. Are there any other simple methods that might increase exercise in obese subjects?

2. Are pedometers available for patients in your area? How would you access one for your patient?

3. Should exercise be individually prescribed?

Question 8

A 45 year old male attends for advice regarding his weight. He has tried a new weighing machine at the pharmacy and this has informed him that he has a problem with his weight. Consequently, he is seeking appropriate advice and comes to your clinic. He is concerned as he has a strong family history of diabetes and has put on weight over the years.

His weight is 92 kg and his height is 179cm, giving a BMI of 28.8 kg/m

. You also note that he has a waist circumference of 103 cm.

What does this waist circumference suggest in this man?

The BMI is not the entire picture when we consider anthropometry. Waist circumference provides a lot more information regarding the level of 'fatness'. For example, a fit rugby player may have a high BMI, even within the obese range but his risk of diabetes, heart disease etc would be low, as his weight would be mostly muscle. Typically, his waist circumference would be quite low - possibly 94 cm or less, reflecting a small amount of visceral adiposity. However, in our patient, whilst the BMI tells us that he is overweight, the high waist circumference suggests that there is considerable abdominal fat.

 is a better predictor of both cardiovascular risk and diabetes than BMI alone with a low waist circumference being less than 94cm, a high waist circumference being 94-102 and a very high waist circumference above 102 cm in a male. These figures in a female are low <80cm, high 80 – 88cm and very high > 88cm. Central adiposity is a key component of the metabolic syndrome – a constellation of features which predispose to increased risk of diabetes and heart disease.

Metabolic syndrome and waist circumference at the 

Patient information on the metabolic syndrome 

2. What disorders are associated with the metabolic syndrome and to what extent?

3. What is the value of waist circumference over BMI in determining risk?

Question 9

A 52 year old male has been to see his GP as he has had problems with his weight and blood pressure. He has been diagnosed with hypertension, having a blood pressure of 154/82 mmHg and he has been given a prescription for amlodipine 5mg daily. He has also been told by the GP to enroll into your weight management programme.

He informs you that he has had a problem with his weight for at least 8 years. His BMI is 34.6 kg/m

 and his waist circumference is 108cm. He has asked his GP about drugs that might help with his weight loss but he would rather try dieting first. He has been told that he should aim for a 5kg weight loss initially over the next six months and he wants to know what the effect of this weight loss would have on his blood pressure.

What do you tell him regarding the effect of this weight loss on his blood pressure?

In addition to the other beneficial effects that exercise has on your health, weight loss itself has been shown to effectively reduce blood pressure. 

 suggest that a 5kg reduction in weight is associated with an average 5 mmHg fall in systolic blood pressure. Although this doesn't seem much, to put it into context it is similar to the fall seen with antihypertensives and would certainly complement these agents.

Other approaches that should be recommended to this man in terms of lifestyle advice that might help to reduce his blood pressure include 

, as well as only drinking alcohol moderately. Simple manoeuvres such as the 

 programme with a pedometer are associated with a fall in systolic blood pressure of 3.6 mmHg!

http://www.netdoctor.co.uk/diseases/facts/hypertension.htm

http://www.nhs.uk/news/2007/November/Pages/Pedometersmakethosestepscount.aspx

1. How does exercise cause a reduction in blood pressure?

2. What is the typical blood pressure lowering effect of an antihypertensive agent?

3. What is the recommended salt intake and by how much on average do we exceed this in the western world?

Weight Management

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