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Weight Loss

July 29, 2017

Obesity (BMI > 30 kg/m2) is prevalent in one-in-four adult Canadians and one-in-10 children.

Excessive body weight contributes to hypertension, type 2 diabetes, cardiovascular disease, dyslipidemia, arthritis, cancer, sleep apnoea, chronic pain, depression, and dementia.

The Framingham Study estimated that overweight and obesity account for ~26% of cases of hypertension in men and ~28% in women. A 2009 systematic review found that even for patients with BMI of <35 kg/m2, a weight loss of only 3 kg was associated overall with reduced blood pressure

Although higher BMIs and wider waist circumferences (more than 94 cm, or 37 inches, in men and more than 80 cm, or 31.5 inches, in women) predict obesity risk, the Edmonton Obesity Staging System (EOSS) is a more accurate predictor of long-term mortality.

Obese children are likely to become obese adults and genetics account for over 75% of BMI.

BMI tends to increase during most of adult life, peaking at age 60, as resting metabolic rate declines by approximately 150 kcal/day per decade. The primary focus of obesity management is to prevent further weight gain.

Most weight loss programs fail because the body takes corrective steps to counteract weight loss once it has become accustomed to a certain weight. The body tries to defend its highest weight. For every 10 pounds of weight lost, the resting metabolic rate drops by 3%. During prolonged periods of fasting, the metabolic rate also slows dramatically.

Diet and Exercise

what you should know before you start a weight loss plan

The recommended rate of weight loss is 1-2 lbs per week and the initial goal is to lose 5-10% of body weight. This can be achieved by consuming 500-1,000 fewer kcal per day (myFitnessPal). Reducing calories will lead to similar weight loss at 2 years irrespective of the specific diet chosen. The general principles involve increasing  intake of vegetables, fruits, high-fiber and whole-grain foods while restricting dietary sugar and sugar-sweetened beverages.

Medications

Prescription treatment for obesity in Canada includes 2 drugs, liraglutide (0.6 mg to 3mg/day injection) and orlistat (120 mg three times daily with meals). They are approved for use in patients with an initial BMI >27 kg/m2  in the presence of weight-related comorbidity, and who have failed a previous weight management intervention or who have a BMI of 30 kg/m2 or more.

In a 56-week study using liraglutide, 33.1% of patients had lost more than 10% of their body weight and 63.2% had lost at least 5% of their body weight. During a 4-year study using orlistat, 73% of patients lost ≥ 5% and 41% of patients lost ≥ 10% of their body weight after 1 year. After 4 years, 44.8% and 21% of the patients treated with orlistat lost ≥ 5 and ≥ 10% of body weight respectively.

Both medications cause gastrointestinal side-effects

Bariatric surgery is considered with a BMI ≥ 40 or ≥ 35 kg/m2 in the presence of comorbid conditions. There are various types of surgeries: Roux-en-Y gastric bypass, biliopancreatic diversion, gastric banding or vertical sleeve gastrectomy may be performed.

Important components of weight management include mental health, sleep apnoea treatment, and pain control to encourage physical activity.

Both diet and physical activity are important for long-term weight management.

Do you have Binge Eating Disorder (BED)?

You can take a screening test here: Binge Eating Scale

  • Are there times when you feel that your eating is out of control?
  • Do you have any concerns about your eating behaviour?
  • Do you ever eat in secret because you are embarrassed by how much you are eating?
  • Do you eat sometimes when you are not hungry?

BED is defined as recurrent episodes of binge eating, on average, at least once per week for three months with a sense of lack of control and feelings of distress but there are no inappropriate compensatory behaviours (these are found in bulimia nervosa- Eating Disorder Diagnostic Scale).

Not all emotional eating is abnormal (sugar stimulates the limbic system in the same manner in which cocaine does). About 2.8% of the general population suffers from BED, women are more likely to be affected than men, and there are often coexisting mental health problems.

The treatment of BED starts with behavioural and psychotherapy (Treatment for Binge Eating Disorder)

Lisdexamfetamine dimesylate is the only approved prescription treatment for moderate to severe (3 or more episodes per week) binge eating disorder in Canada. It is started at 30mg per day and increased by 20mg per week to the target of 50-70mg. It is not a good choice for patients with cardiovascular disease (it is a stimulant that will increase blood pressure and heart rate), glaucoma or on antidepressants. Other drugs are used off-label (antidepressants; anticonvulsants; substance abuse treatments i.e., acamprosate, baclofen, naltrexone; atomoxetine; liraglutide; orlistat).

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