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The One Minute Counselor
he.
A Pharmacist's Guide to Weight Management
neMinute
~ Counselor Look around you. Every other person you see is likely overweight or obese! By definition, this means that lout of2 people has a body mass index (BMI) > 25 kg/m2 . BMI is the measurement recommended by the World Health Organization and is used to assess the risks and consequences of being overweight/obese (Table 1). The overweight/obese population is subject to profound medical and economic consequences.
Obesity as a Chronic . Disease Obesity fulfills many of the criteria that defme a chronic disease. The basic etiology of obesity is relatively simple: caloric intake exceeds caloric expenditure. However, the underlying etiology also includes genetic, physiologic, environmental, and psychological factors. Similar to the co-morbid diseases linked to obesity-hypertension, type 2 diabetes, and hyperlipidemia-obesity treatment needs to focus on long-term control or maintenance of weight loss.
Treatment Large weight loss is not the healthrelated goal for the majority of overweight/obese patients. Losses of 5% to 10% have been shown to reduce blood pressure, improve glycemic control, and lower serum lipid levels. Losses < 5% have shown insignificant effects on these outcomes.
Table 1. BMI Classification Weight Classification
Obesity Class
Underweight
> 18.5
18.5 - 24.9
Normal Overweight
25 - 29.9
Obese
30- 34.9 35 - 39.9
I IT
> 40
IT
Extremely obese
aBMI calculation: (1) # Ibsl2.2 = kg; (2) height (inches) x 0.0254 = meter (m) square this value' (3) kglm2 =BMI. " Adapted from the National Heart, Lung, and Blood Institute Expert Panel on Obesity.
Options for weight loss include changes in diet, behavior modification, physical activity, pharmacotherapy, surgery, and alternative methods such as acupuncture. Changes in diet usually involve a reduction in calories (e.g., very low calorie diets in which intake is reduced to less than 800 to 1,000 calories/day with expected weight loss of 1 to 2 Ibs/week or greater and low calorie diets [LCDs] in which intake is reduced to 1,000 to 1,500 calories/day with expected weight loss of 0.5 to 1 Ib/week). In addition, physical activity is crucial for weight loss and maintenance. Upon approval and guidance by their physician, patients may consult local resources (e.g., YMCA) in their community or Internet sites such as www .nhlbi.nih. gov/health/public/heart/ obesity/lose_wt/phy_act.htm to learn about physical activity guidelines for weight loss maintenance. Other diet programs that incorporate supplements or het:bals such as Ma huang (ephedra), caffeine, Garcinia
cambogia (hydroxycitric acid), capsaicin, L-camitine, bromelains, chitosan, chromium picolinate, Commiphora mukul (guggal), or pyruvate are not supported by data from human trials to warrant their use (and expense). Surgery is reserved for those patients who are morbidly obese. Pharmacotherapy has primarily consisted of agents that influence appetite control and/or thermogenesis, namely, overthe-counter agents (e.g., phenylpropanolamine) and prescription agents such as phentermine and other sympathomimetics. More recently, two drugs (Table 2) have been marketed that promote weight loss by (1) affecting serotonin and norepinephrine (Sibutramine-Meridia) and (2) inhibiting absorption of dietary fat (Orlistat-Xenical). These two agents are indicated only for patients with BMI > 30 kg/m2 or for patients with BMI > 27 kg! m 2 with co-morbidities such as hypertension, diabetes, or hyperlipidemia.
Contributing author: Kim Thrasher, PharmD, is associate director, Department of Pharmacotherapy, UNC Coastal Area Health Education Center, Wilmington, N. C.
This program was developed by
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and
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Table 2. New Agents: Important Points Drug
Dosage
Cautions
Counseling Points
Meridia (Sibutramine)
10 mg daily; range: 5-15 mg daily
Preexisting heart disease,arrhythmias, congestive heart failure; concurrent serotonergic agent use
Use with hypocaloric diet; monitor BP, HR; common side effects are constipation, insomnia, dry mouth; avoid drugs that inhibit CYP3A4
Xenical (Orlistat)
120mg with meals
Pregnancy or breastfeeding; cholestasis; malabsorption syndromes
Use with hypocaloric diet; keep fat < 30% total calories, divide ~ong 3 meals to minimize GI side effects; > 30% fat will increase risk of GI side effects; multivitamins should not be taken within 2 hours of dose
© 2000 by the American Pharmaceutical Association. All rights reserved.
A Patient's Guide to Weight Loss and Weight Loss Maintenance Are you aware of the newest definition for obesity and overweight? Table 1 lists the definitions for the measurement called body mass index (BMI); this measurement assesses your weight in association with your height. Weight is highly associated with your risk for developing heart disease, high blood pressure (BP),. high cholesterol, and diabetes as well as your risk of death. Results from a 14-year evaluation of more than 110,000 nonsmoking women showed that risk for heart dis- . ease doubled when BMI increased from 25 to 28.9 kg/m2 and tripled when BMI was> 29 kg/m2. Similarly, as the number of overweight people increases, so does the risk of developing high BP. Ninety percent of patients with type 2 diabetes have BMIs > 22 kg/m2. Increased BMI is highly related to higher levels of cholesterol and lowdensity lipoproteins ("bad" cholesterol). Is it true that greatly reducing your weight will have beneficial effects on your blood pressure (BP), blood sugar, and cholesterol? No, not necessarily. If your BMI is < 40 kg/m2 (above 40, gastric surgery may be recommended), weight losses of 5% to 10% of your total body weight has been shown in many studies to provide significant decreases in high BP, blood sugar, and cholesterol! You may work with your doctor to determine your BMI and reasonable weight loss goals. Being overweight or obese is a chronic disease, not just a cosmetic concern, and needs to be treated like other chronic diseases, such as high BP. The goal of treatment is ·not for short-term weight loss, rather long-term control. Similarly, after initial weight loss is achieved, weight loss maintenance is crucial to prevent or improve other
diseases such as diabetes or heart disease. Most individuals can lose weightmaintaining weight loss is much more difficult. Weight loss of ~ to 1 pound weekly is a very reasonable goal, and· this can be attained by reducing 300 to 500 calories daily and restricting calories from fat to less than 30% of the total. A dietitian can design a specific diet plan for you. Physical activity is essential for both weight loss and maintenance. Importantly, once obese patients have lost weight, their body wants to conserve calories; therefore, one cannot resume the previous caloric intake that "maintained" their weight in the past. Typically, after weight loss, individuals need 15% less calories than their intake prior to weight loss in order to prevent weight re-gain. Supplements such as Ma huang (ephedra), caffeine, Garcinia cambogia (hydroxycitric acid), capsaicin, L-carnitine, bromelains, chitosan, chromium picolinate, Commiphora mukul (guggal), or pyruvate do not have data from human trials to support their use (or expense or danger). Medications for weight loss have not been consistently helpful. Two new agents may provide more promise to assist the individual already using a diet and exercise program. Meridia
(sibutramine) affects serotonin, a substance that governs appetite control, and norepinephrine, which affects the body's energy expenditure rate. Meridia taken with a low calorie diet has been shown in studies to produce weight loss and maintenance greater than that seen with diet and placebo. You may not be able to use Meridia if you have high BP, high heart rate, heart disease, or if you are on other medicines that affect the ,body's serotonin level. Xenical (orlistat) works by decreasing the amount of dietary fat absorbed from the gastrointestinal tract. Two studies evaluating Xenical and diet, compared with diet and placebo, have shown it to be superior in providing weight loss> 5% in the majority of patients. You should not take Xenical if you are pregnant, breastfeeding, or have food malabsorption conditions. Be aware that side effects of Xenical depend upon the amount of fat eaten; if you do not keep your dietary fat intake less than 30% of your total daily calories, you will increase your chance of side effects of Xenical-oily stools, spotting, and flatus (gas). Know your BMI and your options in achieving your weight loss goals. Weight loss and maintaining weight loss is vital to your future health.
Table 1. 8MI Cla,sification Obesity Class
Weight Classification Underweight Normal Overweight Obese Extremely obese
> 18.5 18.5 -24.9
25 - 29.9 30-34.9 35 -39.9 > 40
I
IT IT
aBMI calculation: (1) # Ibs/2.2 = kg; (2) height (inches) x 0.0254 =meter (m), square this value; (3) kg/m2 = BMI. Adapted from the National Heart, Lung, and Blood Institute Expert Panel on Obesity.
Photocopy this page and give it to appropriate patients. © 2000 by the American Pharmaceutical Association. All rights reserved.
A Pharmacist's Guide to Weight Management
neMinute
~ Counselor Look around you. Every other person you see is likely overweight or obese! By definition, this means that lout of2 people has a body mass index (BMI) > 25 kg/m2 . BMI is the measurement recommended by the World Health Organization and is used to assess the risks and consequences of being overweight/obese (Table 1). The overweight/obese population is subject to profound medical and economic consequences.
Obesity as a Chronic . Disease Obesity fulfills many of the criteria that defme a chronic disease. The basic etiology of obesity is relatively simple: caloric intake exceeds caloric expenditure. However, the underlying etiology also includes genetic, physiologic, environmental, and psychological factors. Similar to the co-morbid diseases linked to obesity-hypertension, type 2 diabetes, and hyperlipidemia-obesity treatment needs to focus on long-term control or maintenance of weight loss.
Treatment Large weight loss is not the healthrelated goal for the majority of overweight/obese patients. Losses of 5% to 10% have been shown to reduce blood pressure, improve glycemic control, and lower serum lipid levels. Losses < 5% have shown insignificant effects on these outcomes.
Table 1. BMI Classification Weight Classification
Obesity Class
Underweight
> 18.5
18.5 - 24.9
Normal Overweight
25 - 29.9
Obese
30- 34.9 35 - 39.9
I IT
> 40
IT
Extremely obese
aBMI calculation: (1) # Ibsl2.2 = kg; (2) height (inches) x 0.0254 = meter (m) square this value' (3) kglm2 =BMI. " Adapted from the National Heart, Lung, and Blood Institute Expert Panel on Obesity.
Options for weight loss include changes in diet, behavior modification, physical activity, pharmacotherapy, surgery, and alternative methods such as acupuncture. Changes in diet usually involve a reduction in calories (e.g., very low calorie diets in which intake is reduced to less than 800 to 1,000 calories/day with expected weight loss of 1 to 2 Ibs/week or greater and low calorie diets [LCDs] in which intake is reduced to 1,000 to 1,500 calories/day with expected weight loss of 0.5 to 1 Ib/week). In addition, physical activity is crucial for weight loss and maintenance. Upon approval and guidance by their physician, patients may consult local resources (e.g., YMCA) in their community or Internet sites such as www .nhlbi.nih. gov/health/public/heart/ obesity/lose_wt/phy_act.htm to learn about physical activity guidelines for weight loss maintenance. Other diet programs that incorporate supplements or het:bals such as Ma huang (ephedra), caffeine, Garcinia
cambogia (hydroxycitric acid), capsaicin, L-camitine, bromelains, chitosan, chromium picolinate, Commiphora mukul (guggal), or pyruvate are not supported by data from human trials to warrant their use (and expense). Surgery is reserved for those patients who are morbidly obese. Pharmacotherapy has primarily consisted of agents that influence appetite control and/or thermogenesis, namely, overthe-counter agents (e.g., phenylpropanolamine) and prescription agents such as phentermine and other sympathomimetics. More recently, two drugs (Table 2) have been marketed that promote weight loss by (1) affecting serotonin and norepinephrine (Sibutramine-Meridia) and (2) inhibiting absorption of dietary fat (Orlistat-Xenical). These two agents are indicated only for patients with BMI > 30 kg/m2 or for patients with BMI > 27 kg! m 2 with co-morbidities such as hypertension, diabetes, or hyperlipidemia.
Contributing author: Kim Thrasher, PharmD, is associate director, Department of Pharmacotherapy, UNC Coastal Area Health Education Center, Wilmington, N. C.
This program was developed by
~
and
a~~p
Table 2. New Agents: Important Points Drug
Dosage
Cautions
Counseling Points
Meridia (Sibutramine)
10 mg daily; range: 5-15 mg daily
Preexisting heart disease,arrhythmias, congestive heart failure; concurrent serotonergic agent use
Use with hypocaloric diet; monitor BP, HR; common side effects are constipation, insomnia, dry mouth; avoid drugs that inhibit CYP3A4
Xenical (Orlistat)
120mg with meals
Pregnancy or breastfeeding; cholestasis; malabsorption syndromes
Use with hypocaloric diet; keep fat < 30% total calories, divide ~ong 3 meals to minimize GI side effects; > 30% fat will increase risk of GI side effects; multivitamins should not be taken within 2 hours of dose
© 2000 by the American Pharmaceutical Association. All rights reserved.
A Patient's Guide to Weight Loss and Weight Loss Maintenance Are you aware of the newest definition for obesity and overweight? Table 1 lists the definitions for the measurement called body mass index (BMI); this measurement assesses your weight in association with your height. Weight is highly associated with your risk for developing heart disease, high blood pressure (BP),. high cholesterol, and diabetes as well as your risk of death. Results from a 14-year evaluation of more than 110,000 nonsmoking women showed that risk for heart dis- . ease doubled when BMI increased from 25 to 28.9 kg/m2 and tripled when BMI was> 29 kg/m2. Similarly, as the number of overweight people increases, so does the risk of developing high BP. Ninety percent of patients with type 2 diabetes have BMIs > 22 kg/m2. Increased BMI is highly related to higher levels of cholesterol and lowdensity lipoproteins ("bad" cholesterol). Is it true that greatly reducing your weight will have beneficial effects on your blood pressure (BP), blood sugar, and cholesterol? No, not necessarily. If your BMI is < 40 kg/m2 (above 40, gastric surgery may be recommended), weight losses of 5% to 10% of your total body weight has been shown in many studies to provide significant decreases in high BP, blood sugar, and cholesterol! You may work with your doctor to determine your BMI and reasonable weight loss goals. Being overweight or obese is a chronic disease, not just a cosmetic concern, and needs to be treated like other chronic diseases, such as high BP. The goal of treatment is ·not for short-term weight loss, rather long-term control. Similarly, after initial weight loss is achieved, weight loss maintenance is crucial to prevent or improve other
diseases such as diabetes or heart disease. Most individuals can lose weightmaintaining weight loss is much more difficult. Weight loss of ~ to 1 pound weekly is a very reasonable goal, and· this can be attained by reducing 300 to 500 calories daily and restricting calories from fat to less than 30% of the total. A dietitian can design a specific diet plan for you. Physical activity is essential for both weight loss and maintenance. Importantly, once obese patients have lost weight, their body wants to conserve calories; therefore, one cannot resume the previous caloric intake that "maintained" their weight in the past. Typically, after weight loss, individuals need 15% less calories than their intake prior to weight loss in order to prevent weight re-gain. Supplements such as Ma huang (ephedra), caffeine, Garcinia cambogia (hydroxycitric acid), capsaicin, L-carnitine, bromelains, chitosan, chromium picolinate, Commiphora mukul (guggal), or pyruvate do not have data from human trials to support their use (or expense or danger). Medications for weight loss have not been consistently helpful. Two new agents may provide more promise to assist the individual already using a diet and exercise program. Meridia
(sibutramine) affects serotonin, a substance that governs appetite control, and norepinephrine, which affects the body's energy expenditure rate. Meridia taken with a low calorie diet has been shown in studies to produce weight loss and maintenance greater than that seen with diet and placebo. You may not be able to use Meridia if you have high BP, high heart rate, heart disease, or if you are on other medicines that affect the ,body's serotonin level. Xenical (orlistat) works by decreasing the amount of dietary fat absorbed from the gastrointestinal tract. Two studies evaluating Xenical and diet, compared with diet and placebo, have shown it to be superior in providing weight loss> 5% in the majority of patients. You should not take Xenical if you are pregnant, breastfeeding, or have food malabsorption conditions. Be aware that side effects of Xenical depend upon the amount of fat eaten; if you do not keep your dietary fat intake less than 30% of your total daily calories, you will increase your chance of side effects of Xenical-oily stools, spotting, and flatus (gas). Know your BMI and your options in achieving your weight loss goals. Weight loss and maintaining weight loss is vital to your future health.
Table 1. 8MI Cla,sification Obesity Class
Weight Classification Underweight Normal Overweight Obese Extremely obese
> 18.5 18.5 -24.9
25 - 29.9 30-34.9 35 -39.9 > 40
I
IT IT
aBMI calculation: (1) # Ibs/2.2 = kg; (2) height (inches) x 0.0254 =meter (m), square this value; (3) kg/m2 = BMI. Adapted from the National Heart, Lung, and Blood Institute Expert Panel on Obesity.
Photocopy this page and give it to appropriate patients. © 2000 by the American Pharmaceutical Association. All rights reserved.