7 Diet, a professional guide for weight loss
Overview
This is a professional guidance for weight loss, include 7 STEPS WHICH ARE designed for clinical nutritionists to help overweight and obese patients. As a nutritionist, you should assess patients and document properly. Measure height, weight, and body mass index (BMI) at least annually in adults. Access a BMI calculator at: http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.html (includes calculator app for iPhone and Android) Identify adults who may be at increased risk of cardiovascular disease and mortality due to weight. Overweight (BMI 25 to 29.9 kg/m²) and obese (BMI ≥30 kg/m²).
- Use risk assessment tools at recommended time intervals, such as every three to five years for overweight or obese adults with type 2 diabetes patients. Examples include Common Cardiovascular Risk Calculators (Cardiovascular Risk Calculator Apps for Smartphones)...
- Statcoder (http://statcoder.wordpress.com/category/cardiovascular-risk/) provides 2013 Pooled Cohort Equations CV Risk Calculator, ATP III, Framingham, and Reynolds for iPhone, iPod Touch, and iPad (free).
- Calculate (http://www.qxmd.com/specialty/medicine/cardiology-medical-apps-iphone-blackberry-android) includes Framingham and Reynolds Risk Score for iPhone, iPad, and Android tablets and smartphones (free).
- 2013 Pooled Cohort Equations CV Risk Calculator (https://itunes.apple.com/us/app/2013-pooled-cohort-equations/id754470890?mt=8) for iPhone, iPad, iPod Touch, iPad (free).
- American Heart Association (https://www.acc.org/tools-and-practice-support/mobile-resources/features/2013-prevention-guidelines-ascvd-risk-estimator) provides the ASCVD Risk Estimator Plus free for iPhone, iPad, and Android.
- ScyMed (https://play.google.com/store/apps/details?id=com.scymed.android.ascvdrisk) has 2013 Pooled Cohort Equations CV Risk Calculator for Android (free).
- CANRISK (Canadian Diabetes Risk) at www.publichealth.gc.ca/CANRISK.
- FINDRISC (Finnish Type 2 Diabetes Risk Score) at https://canadiantaskforce.ca/tools-resources/type-2-diabetes-2/type-2-diabetes-clinician-findrisc/.
- Screen children and adolescents six years and older for obesity. Access a BMI calculator for children and teens at https://www.cdc.gov/healthyweight/bmi/calculator.html.
7 Diet guide for weight loss
STEP 1. Recommend calorie intake reduction for adults.
Recommend a diet with reduced calorie intake for overweight or obese individuals to lose about one to 1.5 pounds per week, such as: 1200 to 1500 kcal/day for women and 1500 to 1800 kcal/day for men.
Access sample reduced-calorie daily menus at http://www.nhlbi.nih.gov/health/educational/lose_wt/eat/menus.htm.
Consider patient preferences and health status with regard to diet. Keep in mind “named” diets such as Zone, Nutrisystem, Atkins, etc., seem to produce similar weight loss. Those with more structured interventions such as Jenny Craig may show slightly better results for the first six months.
| Table (1). Websites for patient health status | |
|---|---|
| Type of diet | Websites |
| Low-carbohydrates diets | Atkins (www.atkins.com) |
| Paleo (http://thepaleodiet.com) | |
| South Beach (www.southbeachdiet.com) | |
| Low-fat diets | Ornish (www.ornishspectrum.com) |
| Pritikin (www.pritikin.com) | |
| Balanced diets | Jenny Craig (www.jennycraig.com) |
| Nutrisystem (www.nutrisystem.com) | |
| Weight Watchers (www.weightwatchers.com) | |
| Zone (www.drsears.com) | |
A large, consistent body of research supports the Mediterranean diet’s cardiovascular benefits. For a short description of the Mediterranean diet, see https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/mediterranean-diet.
STEP 2. Recommend increasing physical activity as appropriate.
Recommend physical activity to contribute to weight loss. For adults, start with 30 to 45 minutes of moderate-intensity physical activity (e.g., brisk walking, water aerobics, light bicycling) three to five days a week. Set a goal to increase to at least 30 minutes of moderate-intensity physical activity on most (preferably all) days of the week. Children should get at least 60 minutes of physical activity each day.
STEP 3. Employ behavior therapy.
Recommend participation in a comprehensive lifestyle program (e.g., diet; exercise; and counseling, education, or support) for at least six months for patients who are overweight or obese. This is also the preferred option for overweight and obese children and youth.
The Noom app shows promise as an alternative to the in-person education and support component in adults. Recommend long-term participation in a weight-maintenance program for those who have lost weight.
STEP 4. Treat with medications that can help with weight loss when appropriate.
Use pharmacotherapy in addition to behavioral modifications when possible for adults with BMI ≥ 27 kg/m² with a comorbidity (e.g., dyslipidemia, hypertension, type 2 diabetes) or BMI > 30 kg/m². (Note that Canadian guidelines recommend against the routine use of pharmacotherapy for weight loss).
Although orlistat and liraglutide, are approved for use in adolescents, pharmacotherapy is not the preferred method of weight loss in children. Metformin has a small benefit that may not be clinically significant. Choose drug therapy based on side effects, comorbid conditions, and cost. Monitor patients using weight loss medications for safety and efficacy monthly for the first three months then every three months thereafter. Use drug therapy on a chronic basis to sustain weight loss and control comorbidities such as type 2 diabetes and hypertension.
Discontinue treatment if the patient doesn’t lose at least ~5% of body weight after 12 weeks on a maximum dose. Consider an alternative medication or treatment. (Saxenda [liraglutide]: consider an alternative if pediatric patients do not have at least a 1% reduction in BMI after 12 weeks). Counsel patients regarding the use of supplements for weight loss, such as about potential side effects (e.g., increased blood pressure and heart rate) from ephedrine and other stimulant-containing supplements, as well as the lack of proof for efficacy for many supplements marketed for weight loss (e.g., garcinia, green coffee extract).
| Table (2). Pharmacotherapy for Obesity | ||||
|---|---|---|---|---|
| Drug (Generic) | Dosage | Mechanism of Action | Common Side Effects | Contraindications |
| Phentermine resin | AdipexP (37.5 mg), 37.5 mg/d Ionamin (30 mg), 30–37.5 mg/d | Norepinephrine-releasing agent | Headache, elevated BP, elevated HR, insomnia, dry mouth, constipation, anxiety Cardiovascular: palpitation, tachycardia, elevated BP, ischemic events Central nervous system: overstimulation, restlessness, dizziness, insomnia, euphoria, dysphoria, tremor, headache, psychosis Gastrointestinal: dryness of the mouth, unpleasant taste, diarrhea, constipation, other gastrointestinal disturbances Allergic: urticaria Endocrine: impotence, changes in libido | Anxiety disorders (agitated states), history of heart disease, uncontrolled hypertension, seizure, MAO inhibitors, pregnancy and breastfeeding, hyperthyroidism, glaucoma, history of drug abuse, sympathomimetic amines |
| Diethylpropion | Tenuate (75 mg), 75 mg/d | Norepinephrine-releasing agents | see Phentermine resin | see Phentermine resin |
| Orlistat, prescription (120 mg) | 120 mg TID | Pancreatic and gastric lipase inhibitor | Decreased absorption of fat-soluble vitamins, steatorrhrea, oily spotting, flatulence with discharge, fecal urgency, oily evacuation, increased defecation, fecal incontinence | Cyclosporine (taken 2 h before or after orlistat dose), chronic malabsorption syndrome, pregnancy and breastfeeding, cholestasis, levothyroxine, warfarin, antiepileptic drugs |
| Orlistat, over-the-counter (60 mg) | 60–120 mg TID | Pancreatic and gastric lipase inhibitor | See Orlistat, prescription | See Orlistat, prescription |
| Lorcaserin (10 mg) | 10 mg BID | 5HT2c receptor agonist | Headache, nausea, dry mouth, dizziness, fatigue, constipation | Pregnancy and breastfeeding Use with caution: SSRI, SNRI/MAOI, St John's wort, triptans, buproprion, dextromethorphan |
| Phentermine (P)/topiramate (T) | 3.75 mg P/23 mg T ER QD (starting dose) 7.5 mg P/46 mg T ER daily (recommended dose) 15 mg P/92 mg P/T ER daily (high dose) | GABA receptor modulation (T) plus norepinephrine-releasing agent (P) | Insomnia, dry mouth, constipation, paraesthesia, dizziness, dysgeusia | Pregnancy and breastfeeding, hyperthyroidism, glaucoma, MAO inhibitor, sympathomimetic amines |
| Naltrexone/bupropion | 32 mg/360 mg 2 tablets QID (high dose) | Reuptake inhibitor of dopamine and norepinephrine (bupropion) and opioid antagonist (naltrexone) | Nausea, constipation, headache, vomiting, dizziness | Uncontrolled hypertension, seizure disorders, anorexia nervosa or bulimia, drug or alcohol withdrawal, MAO inhibitors |
| Liraglutide | 3.0 mg injectable | GLP-1 agonist | Nausea, vomiting, pancreatitis | Medullary thyroid cancer history, multiple endocrine neoplasia type 2 history |
STEP 5. Steer away from drugs that cause weight gain, if possible AND Support patients who have had bariatric surgery.
For overweight or obese patients with type 2 diabetes, consider diabetes medications that are either weight neutral or that lead to weight loss. Bariatric surgery can be considered for certain individuals with BMI ≥ 35 kg/m² with an obesity-related comorbidity or BMI > 40 kg/m².
| Table (3). Medications Associated with Weight Gain | |
|---|---|
| Class | Medications |
| Psychotropic agents | Antidepresssant drugs (tricyclic antidepressants, monoamine oxidase inhibitors) |
| Antipsychotic drugs | |
| Lithium | |
| Anticonvulsants agents | Valproic acid (Depakene) |
| Carbamazepine (Tegretol) | |
| Steroids hormones | Corticosteroids |
| Estrogen, progesterone, testosterone or other anabolic/androgenic steroids | |
| Insulin and most oral hypoglycemic agents | |
| Information from Pijl H, Meinders AE. Bodyweight change as an adverse effect of drug treatment. Mechanisms and management. Drug Saf 1996;14:329–42. | |
STEP 6. Encourage patients by sharing information.
Make overweight and obese individuals/caregivers aware of the health benefits of weight loss. Sustained weight loss of around 5% of body weight can lead to improvements in blood pressure, blood glucose, and lipids, as well as a reduced need for some medications such as statins and diabetes medications. Weight loss may help improve physical functioning and ability to increase physical activity.
Advise adults that greater BMI and waist circumference are associated with increased risk of cardiovascular disease, type 2 diabetes, and all-cause mortality. Advise caregivers that in children, excess body fat is associated with adulthood obesity. Childhood obesity is associated with high blood pressure, dyslipidemia, sleep apnea, asthma, orthopedic problems, polycystic ovary disease, early maturation, and fatty liver.
The 5-2-1-0 mnemonic (5 or more fruit/vegetable servings, ≤ 2 hours’ screen time, ≥ 1 hour of physical activity, and 0 sugary drinks/day) can be used to promote healthy lifestyle choices to children and families. AND access more information about healthy weight loss and the benefits of weight loss.
- CDC at http://www.cdc.gov/HEALTHYWEIGHT/LOSING_WEIGHT/INDEX.HTML.
- Health Canada at http://www.hc-sc.gc.ca/fn-an/nutrition/weights-poids/guide-ld-adult/qa-qr-pub-eng.php#a9.
STEP 7. Help patients keep track of information to meet their goals.
- To find information about calorie content of foods and track caloric intake:
- Food-o-Meter at http://www.webmd.com/diet/healthtool-food-calorie-counter.
- MyFitnessPal at https://www.myfitnesspal.com/ (includes a wide variety of apps compatible with a wide variety of devices).
- To track physical activity and calorie intake, suggest a website or app such as MyFitnessPal (https://www.myfitnesspal.com/)
- For patients who prefer manual logs for diet and exercise...
- A physical activity log is available at American Heart Association (AHA) at https://www.heart.org/-/media/files/health-topics/cardiac-rehab/activity-log.pdf.
- A food log is available at https://www.cdc.gov/diabetes/prevention/pdf/t2/Handouts-Food_Log.pdf.
- The U.S. Department of Health and Human Services (DHHS) has an interactive weekly activity planner “Move Your Way,” available at https://health.gov/moveyourway/activity-planner/activities.
References
- Brauer P, Gorber SC, et al. Recommendations for prevention of weight gain and use of behavioural and pharmacologic interventions to manage overweight and obesity in adults in primary care. CMAJ. 2015 Feb 17;187(3):184-195.
- Apovian CM, Aronne LJ, et al. Pharmacological management of obesity: an endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015 Feb;100(2):342-62.
- Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol. 2014 Jul 1;63(25 Pt B):2985-3023.
- National Institutes of Health. Aim for a healthy weight. http://www.nhlbi.nih.gov/health/educational/lose_wt/recommen.htm.
- Atallah R, Filion KB, Wakil SM, Genest J, et al. Long-term effects of 4 popular diets on weight loss and cardiovascular risk factors: a systematic review of randomized controlled trials. Circ Cardiovasc Qual Outcomes. 2014 Nov;7(6):815-27.
- U.S. Preventive Services Task Force. Obesity in children and adolescents: screening. June 20, 2017. https://uspreventiveservicestaskforce.org/uspstf/recommendation/obesity-in-children-and-adolescents-screening.
- Toro-Ramos T, Michaelides A, et al. Mobile Delivery of the Diabetes Prevention Program in People With Prediabetes: Randomized Controlled Trial. JMIR Mhealth Uhealth. 2020 Jul 8;8(7):e17842.
- Gudzune KA, Doshi RS, Mehta AK, Chaudhry ZW, Jacobs DK, Vakil RM, Lee CJ, Bleich SN, Clark JM. Efficacy of commercial weight-loss programs: an updated systematic review. Ann Intern Med. 2015 Apr 7;162(7):501-12.
- MartÃnez-González MA, Gea A, Ruiz-Canela M. The Mediterranean Diet and Cardiovascular Health. Circ Res. 2019 Mar;124(5):779-798.
- National Institutes of Health. How much physical activity should your family get?. https://www.nhlbi.nih.gov/health/educational/wecan/get-active/physical-activity-guidelines.htm.