Chapter 9 Weight Management: Overweight, Obesity, and ...s3.amazonaws.com/prealliance_oneclass_sample/lz68wDblLO.pdfEnriched Instructor’s Manual to Accompany Understanding Nutrition,

Enriched Instructor’s Manual to Accompany Understanding Nutrition, First Canadian Edition 9-1

Chapter 9Weight Management: Overweight, Obesity, and Underweight

I F N O T H I N G E L S E , M Y S T U D E N T S S H O U L D L E A R N …

1. That the causes of individuals classified as being overweight or obese are numerous, and are based on various theories (e.g., setpoint theory, thrifty gene theory), environmental factors, genetics, and lifestyle factors.

2. The numerous health risks and inaccurate perceptions regarding people who are classified as overweight or obese.

3. That there is no single “cure” or successful intervention for people classified as overweight or obese. Effective weight loss strategies usually incorporate a combination of numerous approaches (e.g., modifying eating plans, engaging in physical activity, eliminating environmental influences).

4. That a significant proportion of people living in Canada are classified as overweight/obese and, as a result, have significant longterm health risks.

L E A R N I N G O B J E C T I V E S

Students should be able to:

• LO 9.1: Explain fat cell development and its role in obesity. [Understand/ Remember]

• LO 9.2: Discuss the role of lipoprotein lipase in obesity. [Understand/ Remember]

• LO 9.3: Discuss the set point theory of obesity. [Understand/Remember]

• LO 9.4: Discuss the role of genetics, leptin, and ghrelin in the development of obesity. [Understand/Remember]

• LO 9.5: Identify environmental causes of obesity. [Understand/Remember]

• LO 9.6: Describe the consequences of obesity including health, social, and psychological problems. [Understand/Remember]

Copyright © 2013 by Nelson Education Ltd.


• LO 9.7: Explain the risks of fad diets, dietary supplements, and herbs in the treatment of obesity. [Understand/Remember]

• LO 9.8: Explain the drugs used to treat obesity and their side effects. [Understand/Remember]

• LO 9.9: Discuss the risks and benefits of surgery for obesity. [Understand/Remember]

• LO 9.10: List strategies for successful weight loss. [Understand/Apply]

• LO. 9.11: Explain the role of exercise in weight management. [Understand/ Apply]

• LO 9.12: Discuss the causes and treatment of underweight. [Understand/ Remember]

• LO 9.13: Evaluate fad diets for effectiveness, safety, and longterm weight control. [Understand/Apply]

W H Y I S T H I S C H A P T E R I M P O R TA N T T O S C I E N T I S T S A N D H E A LT H C A R E P R AC T I T I O N E R S ?

“Of special interest to...” symbol key: = HealthCare Practitioners = Science Majors

• Obesity is a significant health risk for the development of many chronic diseases. Nutrition scientists are continually studying ways to prevent and/or treat obesity, while healthcare practitioners provide frontline treatment/management for people classified as overweight/obese.

• Based upon the relationship between presence of body fat and the development of

chronic disease, scientists have established what they feel is an ideal percentage of body fat. For men (and women), those less than 40 years of age the ideal amount is 22 percent (32%) and for those greater than 40 years of age, the ideal amount is 25 percent (35%).

• Central obesity may be more hazardous to health than other forms of obesity. Exercise scientists are studying ways to alter central obesity by examining the effects of regular exercise programs with and without diet interventions. Such interventions are routinely prescribed by various healthcare practitioners.

• Research has linked obesity with a number of factors such as birth order, number of brothers, marital status, onset of puberty, ethnicity, fastfood consumption, proportion of fat/protein and carbohydrate intake, income, consumption of sugar

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sweeteners, leisure time, education level, sleep habits, alcohol consumption, sedentary behaviour, and television watching. Genetic scientists are identifying potential genetic links with obesity development.

• Many popular diets recommend high protein, low carbohydrate consumption. Nutrition scientists are studying the benefits and risks of consumption of such a diet, both on a shortterm and on a longterm basis.

• Nutritionists who study human behaviour identify stimuli that could lead to overeating. Food pricing, availability, and advertising influence food choices. Physical inactivity is clearly linked with the development of obesity.

W H Y S H O U L D S T U D E N T S C A R E ?

• Most people who are overweight or obese suffer illnesses. Experts estimate health risks from obesity using BMI values, waist circumference, and a disease risk profile. Being overweight presents social and economic handicaps as well as physical capacity limits. Judging people by their body weight is a form of prejudice in our society.

• Students should learn about the trigger signals for hunger and satiety. Hunger is stimulated by “Go” signals such as an absence of food in the digestive tract. Appetite can occur with or without hunger. Satiation occurs when the digestive organs signal the brain that enough food has been consumed. Satiety is the feeling of fullness that lasts until the next meal. Some foods may confer greater satiety than others. Hunger outweighs satiety in the appetite control system. The adipose tissue hormone leptin suppresses the appetite in response to a gain in body fat.

• There are “metabolic theories” of obesity that attempt to explain obesity on the basis of molecular functioning. Students should realize that a person’s genetic inheritance greatly influences the likelihood of obesity.

• It is important for students to have a solid understanding of energy balance and fuel metabolism. When energy balance is negative, the breakdown of glycogen returns glucose to the blood. When glycogen runs out, body protein is broken down to produce glucose. If glucose runs out, fat supplies fuel as ketone bodies, but ketosis can be dangerous. Both prolonged fasts and lowcarbohydrate diets are illadvised. When energy balance is positive, carbohydrate is converted to glycogen or fat, protein is converted to fat, and food fat is stored as fat. Alcohol delivers calories and encourages fat storage.

• Students need to understand that for people (patients, friends, family, or oneself, etc.) to achieve and maintain a healthy body weight, they need to understand that realistic goals should be set, records should be kept, and progress should be slow.



People should watch energy density, make the diet adequate and balanced, limit calories, reduce alcohol, and eat regularly, especially at breakfast.

• Students need to have a solid understanding of basic principles of weight loss and gain. (1) Physical activity greatly augments diet in weight loss efforts and is associated with improvements in health and body composition. (2) Alternatively, weight gain requires a diet of caloriedense foods, eaten frequently throughout the day. Physical activity builds lean tissue, and no special supplements can speed the process. (3) For people whose obesity threatens their health, medical science offers drugs and surgery. However, the effectiveness of herbal products and other gimmicks has not been demonstrated, and they may prove hazardous.

W H AT A R E C O M M O N S T U D E N T M I S C O N C E P T I O N S / S T U M B L I N G B L O C K S ?

1. People who have developed obesity do so as a result of numerous factors. One popular misconception and generalization is that obese people eat too much and are lazy. It is imperative that students develop an understanding of the numerous factors that lead to the development of obesity, including influential genetic and environmental factors.

2. Although some drastic measures are often taken for individuals classified as morbidly obese (e.g., drugs, surgery), students should be aware that other less invasive interventions may prove to be healthier alternatives, which if incorporated into a person’s lifestyle, may have longer lasting benefits.

3. There is a common misconception that low carbohydrate diets are the best for weight loss. Discuss the pros and cons of such diets in class.

4. There is a misconception that a person classified as overweight is unhealthy. However, a person in this weight classification that engages in a sufficient level of daily activity while maintaining an adequate and healthy diet, can lead an active, healthy, and productive lifestyle.

W H AT C A N I D O I N C L A S S ?

There are a variety of activities that can be done in class. Listed below are some activities that will help introduce the topic of nutrition, and the students to each other.

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Critical Thinking Questions1

These questions will also be posted to the book’s website so that students can complete them online and email their answers to you.

1. Briefly describe how each of the following may be a factor related to an individual’s obesity dilemma: a) gender (such as being female) and ethnicity (Black and Hispanic); b) lipoprotein lipase; c) setpoint theory; d) leptin; and e) adiponectin.

2. What are the differences between ghrelin and PYY?

3. What recommendations would you make to an individual who is having problems gaining weight?

4. There are many marketed remedies for weight loss. Distinguish between those that have some proven scientific efficacy and those that do not. How would you help a patient to select the safest approach to weight loss when many patients become so desperate for a quick fix?

5. Your textbook discusses four areas that are all important to an optimal weightloss program. Discuss each area and how you might approach these important strategies to optimize the patient’s weight loss maintenance.

W H AT O T H E R R E S O U R C E S A R E AVA I L A B L E ?

You can look up information about government policy as well as any health condition that you are interested in learning more about. Consult the following web sites to get reliable information on the following:

• Learn out more about overweight Canadian children and adolescents at http://www.statcan.gc.ca/pub/82620m/2005001/pdf/4193660eng.pdf

• The 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children can be found at: http://www.cmaj.ca/cgi/content/full/176/8/S1.

• Practical guidelines for people to incorporate and maintain a healthy level of physical activity can be found at http://www.csep.ca (Canadian Society of Exercise Physiology).

• You can look up the caloric content of foods on the Nutrition website http://www.nutritioncc.nelson.com and follow the links to the Canadian Nutrition file 2007.

• You can check Health Canada’s Natural Health Products Database at http://www.hcsc.gc.ca/dhpmps/prodnatur/indexeng.php to identify the status of

1 Contributed by Kathleen Rourke.


http://www.statcan.gc.ca/pub/82-620-m/2005001/pdf/4193660-eng.pdf

http://www.hc-sc.gc.ca/dhp-mps/prodnatur/index-eng.php

http://www.nutritioncc.nelson.com/

http://www.csep.ca/

http://www.cmaj.ca/cgi/content/full/176/8/S1


herbs or natural products that are promoted for weight loss (e.g., ma huang [ephedra] and phenylpropanolamine).

Two Canadian organizations (listed below) promote the nondiet approach to a healthy lifestyle. Since students with eating disorders often take nutrition courses, instructors should also tell students about programs for eating disorders available at the college or university or in their community.

• The National Eating Disorder Information Centre (NEDIC) provides information through a tollfree phone number (18666334220) or Toronto phone number (4163404156) and the website (http://www.nedic.ca). The website includes a guide for family and friends.

• HUGS International offers support and programs for people seeking a lifestyle without dieting. The website provides a selfprofile quiz (http://www.hugs.com). HUGS International, Box 102A, R.R. #3, Portage la Prairie, Manitoba R1N 3A3 ; Phone: 2044283432.

A N S W E R K E Y F O R A L L I N S T R U C T O R ’ S M A N UA L AC T I V I T I E S

Critical Thinking Questions2

These questions will also be posted to the book’s website so that students can complete them online and email their answers to you.

1. Answer: a) As noted in your textbook, women tend to lay down fatty deposits in different areas than men. Women will accrue more fat in their hips and thighs, while men will accrue more fat in their stomachs. Women also retain a higher fat mass than do men, presumably for pregnancy and lactation. Therefore, there are some physiologic factors that complicate the weightloss equation for a female.

People of Black or Hispanic heritage tend to have a higher prevalence of overweight and obesity. However, it is unclear whether this is genetic or cultural/environmental. Black women, for example, tend to have higher muscle mass when compared to Caucasian women, yet on average are heavier by body and fat weight overall than Caucasian women. Culturally, in both the Black and Hispanic cultures, as well as some other cultures, a higher body weight is not only acceptable but an image of beauty. Therefore, in some cultures, a heavier weight is not necessarily seen as negative.

b) Lipoprotein lipase is the enzyme that breaks down the triglycerides that are in the bloodstream and sends the fats to the cell for storage. Research tells us that lipoprotein lipase (LPL) works well in women at the breast, hips, and thigh sites while in men it works well at the abdomen site in storing fat in the adipose cells. When it comes to the activity of LPL in the release or the breakdown of fat from the

2 Contributed by Kathleen Rourke.

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http://www.hugs.com/

http://www.nedic.ca/


fat cell sites, it appears that the activity of LPL in women is lower for the lower half of the body than that of men, it is the same for both sexes in the top half of the body, and overall, women do have a slower activity by LPL than do men, making it more difficult to break down fat. This factor is most likely associated with childbearing.

c) The setpoint theory proposes that the body, under a condition of change, seeks to return to a state of “homeostasis” by returning to its original weight with weight loss or with weight gain. Regulatory centres in the brain, namely the hypothalamus, are believed to be responsible for seeking to regulate the body’s weight and metabolism. There is scientific evidence to support this theory.

d) Leptin is another protein that acts as a hormone in the hypothalamus to decrease appetite and increase energy expenditure. Discovered within the past decade, leptin has been the subject of significant research. Individuals with differential leptin levels will have remarkable differences in weight, and most interesting is the association between the increase of fructose consumption and leptin resistance, given the extremely high levels of highfructose corn syrup in the diet of the North American public presently. Could it be that this diet is exacerbating obesity even beyond the lack of exercise and large portion sizes?

e) This protein is found in the adipose tissue and is higher in leaner individuals. Adiponectin is important in the prevention of inflammation and protecting individuals against insulin resistance and cardiovascular disease, issues that individuals with obesity consistently suffer from. This is a protein that would be important to the obese individual, yet is higher in the individual who has the leaner body type. The association between low levels of this protein and obesity is an important one.

2. Answer: Ghrelin is a protein that works as a hormone in the hypothalamus. It is secreted in the stomach and acts to maintain a positive energy balance. Ghrelin also plays a role in growth hormone activity and in sleep promotion, the lack of which is associated with increased hunger. PYY is a peptide that is secreted from the GI cells in response to a meal. PYY acts to suppress appetite once the calories of a meal appear to be sufficient, while ghrelin acts as an appetite stimulator. Ghrelin and PYY oppose one another or shut one another off when released simultaneously in the body.

3. Answer: It is not always necessary to have an underweight individual gain weight. Many times, the individual will gain weight as they grow older without any effort. Therefore, it is important to start with an assessment of the individual to ascertain if there are any health risks prior to making any recommendations.

Rationale for making weight changes would include:

• BMI: < 18

• Body fat: < 11% for women, < 7% for men

Blood Work: Blood chemistry, hormone analysis, or kidney function that is out of laboratory limits.

Physical Assessment: Low blood pressure, pale skin tone with poor turgor, brittle nails and hair, overall wasting look.



Recommendations: Assess meal schedule and dietary patterns presently. Discuss food preferences and dislikes. Assess for food allergies.

Add supplemental protein such as oatmeal, powdered milk, or other nutrientdense calorie sources to baked foods such as meatloaf, hamburgers, and stews.

Add nutrientdense snacks between meals. Meals do not have to be huge. Keep at normal size but add supplemental density for calories and nutrition. Encourage inbetween snacks that provide not only calories but vitamins, minerals, and protein. Nuts, dried fruits, peanut butter, etc. are excellent snacks that do not require much preparation, provide much nutrition, and taste good.

Ice cream and nutritional supplement shakes are also a good source of calories and nutrition.

It is good to gain slowly and to watch the weight constantly. Balance weight gain with exercise to allow the patient to develop good habits for a lifetime. Maintain a highfibre diet as well to manage the cholesterol and keep up with regular physicals to monitor all physical parameters.

4. Answer: It can be difficult for the RD to keep up with all the diet fads that come onto the market. Not only are there dietary plans, but there are supplements, exercise programs, and psychological programs that are all sold to consumers who are desperate to lose weight. The fact is that anyone can lose weight on any of these plans if they stick to the plan (no matter how dangerous), but each one varies significantly. Some drastically change how participants live their daily lives and are unrealistic, not to mention possibly dangerous to the body. As discussed in earlier chapters, it is not healthy to deprive the body of any one food group nor to consume massive doses of supplements that have not been well studied. While “herbs” may be believed to be “natural,” nothing is massive quantities is good for the body, including protein. Finally, excessive weight loss in a short period of time also puts unreasonable demands on the body and should not be encouraged.

For the average patient who requires a weight loss of 25 kilograms (50 pounds) or less, the best and safest approach is a reeducation of eating and exercise habits. This includes an intensive look at the role of food in the patient’s life, culture, religion, etc. As we have studied, food takes on many roles and until an individual fully understands his or her relationship with food (how the patient uses food in times of stress, happiness, celebration, etc.), the individual cannot easily lose weight. Part of this process is also learning portion sizes, learning to cook in a healthy and calorie controlled manner, and learning to make exercise part of a daily routine. These are not little changes and do require that the entire family within which a person lives also be a part of the process. One other major piece of this process is the person’s acceptance of him or herself as a good and unique person, just as he or she is (not after losing weight). As the patient and the student will see, this is not a quick process but for those that are willing to undergo the full process, their longterm remission will be far less than the average person who pursues weightloss programs.

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For the individual that is clinically obese (meaning greater than 30% above his or her ideal body weight) and in most instances severely obese (over 50% above ideal body weight), much more aggressive approaches are available. As noted, these include drugs and surgical intervention. As opposed to the overthecounter drugs (with the exception of alli or orlistat) and herbs, these medications have been scientifically tested in Phase III trials and approved by the federal government for treatment of obesity. Given the dramatic increase in obesity in Canada and the United States, research continues to be conducted to determine drugs of efficacy as well as approaches of efficacy to disrupt this disturbing trend.

Sibutramine or Miridia: This drug is a serotonin reuptake inhibitor that is manufactured by Abbott and is a controlled substance. While most reuptake inhibitors are related to antidepressants, Miridia does not appear to function as an antidepressant and is related to the amphetamine group; thus, the side effects related to blood pressure and heart rate. While it appears to be a powerful appetite suppressant, there are many potential side effects for an individual who is severely obese. Strict medical supervision is required when taking this drug.

Orlistat (Xenical or alli): This medication controls weight by inhibiting the absorption of fat in the GI tract. It is available over the counter and can be a very effective form of weight control in the form of negative feedback. Individuals taking orlistat quickly learn that when they consume a diet that is high in fat, they will require close access to a toilet because the drug helps to excrete approximately 30 percent of the fat in the diet, thus reducing the energyyielding nutrients absorbed. The result is loose, runny stools that are unpleasant, which serves as a negative feedback mechanism for the patient taking the drug. Many patients have been very successful on a program of orlistat with diet and exercise, for which the company has hired RDs to educate and instruct individuals. Given the negative feedback loop with the drug, individuals may not be automatically attracted. However, issues of hydration and fatsoluble vitamin supplementation can be problematic for those individuals that do not seek counselling. Because orlistat blocks over 30 percent of fat absorption, vitamins that are fat soluble can be compromised in their absorption. This can be problematic for those individuals who are already on a dietary plan that is insufficient in nutrients. Therefore, individuals pursuing this option should be closely supervised to ensure optimal health and nutrition.

Phentermine (FenPhen, AdipexP, Ionamin) and Bupropion (Welbutrin): Both of these products are an older class of dietary aids. FenPhen was popular almost a decade ago and is an appetite suppressant that is a controlled substance from the amphetamine group. Several physiological consequences from taking amphetamines are of concern and should be monitored in patients taking these drugs.

Welbutrin is an antidepressant that retains multiple purposes. While many individuals do not find the drug effective in the treatment of depression, some may find it effective for appetite suppression.

Topamax: One medication that that your textbook did not mention that is frequently used offlabel for appetite suppression is Topamax. This drug is used to treat seizures and offlabel for nerve pain. Many obesity experts have found it quite effective as an



appetite depressant. It is very possible that we will be hearing more about this drug in the fight regarding obesity in the future, and many individuals have successfully lost weight with the use of this drug.

Gastric Surgery: This procedure has increased in popularity for the treatment of severely obese patients over the decades. What was once a highly risky surgery has now become the mainstay of treatment of the severely obese and the technique has become so perfected that its invasiveness is minimal. However, this surgery is not without risks. Patients are still at risk for infection or sepsis, significant nutrient loss, etc. Patients undergoing this procedure must realize the risks and the commitment to a new life with new habits. Thankfully, many centres are now testing patients psychologically for their readiness for the surgery and the changes they must make after the surgery. There also exists a full team of professionals that work with the patient in terms of diet, exercise, mental health, etc. In the past, the surgery was done for those patients that could afford the surgery without any ancillary services or preliminary testing. In these situations, the success rates were not good.

For all patients, it is important to know their habits and lifestyle individually. Also important to know their support system, cultural beliefs, exercise habits, and psychological profile. From this information, one can better guide patients. Patients are of course often anxious to do the quickest thing on the market. In these instances, work to help patients understand that the quickest thing on the market is probably the most expensive and unreliable alternative product for them because of their profile. Then outline how they can achieve their goals more cost effectively, with support, having fun, and in a reasonable amount of time.

5. Answer: The areas that the textbook mentioned were eating plans, physical activity, environmental influences, and behaviour and attitude.

Eating Plans: It is always important to select an eating program that will provide a balanced diet (one that does not make individuals feel that they are being deprived) and allows for a moderate weight loss. Weight losses of more than 1 kg (2 lbs) a week are rarely sustained and should be discouraged for everyone. Every dietary plan should include all the food groups as that are the best way to get all the nutrients that the body needs to work in an organized fashion.

Energy expenditure, and hence appropriate caloric intake, can be determined by the individual’s height, weight, and age as well as activity level. This should be adjusted monthly as the patient’s body changes.

Nutrients to remember: Always remember that water, fibre, oils, carbohydrates, fruits, and vegetables are needed in one’s diet. As indicated, no food group should be excluded for optimal health status for the individual.

A balance of carbohydrates to fat to protein is needed. Each patient will be different, depending on age, gender, and activity level as well as goals. Carbohydrates at 50–60 percent of the diet and protein at 30–40 percent of the diet are a good mix with oils at no more than 20 percent of the diet. Fatty acids should be chosen from the

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monounsaturated and then polyunsaturated fatty acids and include, at most, 10 percent saturated fatty acids.

Physical Activity: We have discussed many times the importance of physical activity. For the individual that is overweight or obese, activity can be difficult or embarrassing. Encouraging physical activities such as walking, walking the stairs or to the car, etc. is very important. Increasing that activity as weight is lost improves confidence for the individual and increases calorie needs. The individual can also join a gym or class with members who are of like weight so that they can talk about their goals. Socializing in this manner is important. What is most important is moving in any number of ways. The RD who develops a system for patients to reward movement while on a weightloss program will win in more ways than one.

Environmental Influences: The numbers of environmental influences that affect an individual who has weight issues are uncountable. Environment can impact one’s diet profoundly. Culture, ethnicity, religion, etc. vastly influence a person with obesity. For instance, in the German culture, children of a German father are considered to be well taken care of and the father to be a good provider when they are heavy. While pictures within the magazines portray thin, young, “happy” women, culturally most women are not at all considered acceptable within their ethnic groups as they are portrayed in the magazines. This becomes a major dilemma for young women and their families in our culture.

The overall issue is the selfimage of young Canadians. They are confused as to what is ideal. Many young girls and increasingly young men are trying to achieve an unrealistic image of what they are “supposed to be.” Little is discussed about liking themselves or developing a strong self image.

Behaviour and Attitude: Behaviour and attitude are most important to weight loss. When individuals does not believe in themselves, how they can possibly lose weight? Many patients start a weightloss program with other goals. In order to lose weight they must be presented with their own goals. Understanding where they are with regard to their weightloss program and how they feel about themselves is of ultimate importance.

Without this one element, weight loss cannot be achieved. It will be up to the healthcare professionals and the RD to make sure that all of the behavioural components are clearly defined/assessed to work with the other components of the dietary and exercise program in order to optimize the patient’s success.



Worksheet Answer KeyWorksheet 91: Weight Management Medications3

Medication Classification Clinical Indication Monitoring Aspects

Megestrol acetate (Megace)

Orexigenic agent Treatment of metastatic breast cancer, metastatic endometrial cancer; stimulation of appetite and promotion of weight gain in patients with wasting due to AIDS or cancer

Monitor for side effects: increased appetite and weight gain, swelling, hyperglycemia, headache, breast tenderness, impotence, decreased sexual desire, elevated blood pressure

Dronabinol (Marinol)

Orexigenic agent Prevention of nausea/vomiting during cancer treatment; stimulation of appetite in AIDS patients

Monitor for interactions with alcohol and other depressant medications; side effects: dizziness, lightheadedness, or fainting; mental disturbances

Sibutramine hydrochloride monohydrate (Meridia)

Norepinephrine, serotonin and dopamine inhibitor

Weight loss/maintenance in overweight patients

Monitor for side effects: elevated blood pressure or heart rate, allergic reactions, dizziness, drowsiness

Orlistat (Xenical, alli)

Lipase inhibitor Weight loss/maintenance in overweight patients

Monitor for improvement of blood glucose in diabetic patients; monitor for compliance with fatrestricted diet and daily multivitamin supplement; monitor liver function

1. Health Canada; in the United States, the Food and Drug Administration (FDA)

2. Yes

3. See “Monitoring Aspects” column of table.

4. For medications used to promote weight loss or gain, the clinician would monitor the patient’s weight, assess body composition using appropriate techniques, and check for edema/dehydration (changes in fluid balance). If the medication is being used to counteract wasting, a gain of weight (not attributable to fluid retention) would indicate the medication is working. If it is being used to promote weight loss, then loss of weight at a reasonable rate, improvement in blood lipid profile, reduction in blood pressure (for hypertensive patients), and improvement in glycemic control (for diabetic patients) are indications that the medication is benefiting the patient.

5. Sample (U.S.) pricing: Megestrol acetate = $52.99 for 100 40mg tablets; Marinol = $424.67 for 60 2.5mg capsules; Meridia = $109.99 for 30 5mg capsules; Xenical = $325.30 for 90 120mg capsules; alli = $54.99 for “starter pack” with 90 60mg capsules

3 Sources for answer key: Medline Plus: Drugs, Supplements, and Herbal Information. Accessed 26 Oct. 2009 & 8 Nov. 2006, from: http://www.nlm.nih.gov/medlineplus/druginformation.html. Drugstore.com: Drug Information. Accessed 26 Oct. 2009, from: http://www.drugstore.com.

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http://www.drugstore.com/

http://www.nlm.nih.gov/medlineplus/druginformation.html


Worksheet 92: Clinical Application—Bariatric Surgery4

1. Answers will vary.

2. A gastric bypass is a surgical procedure in which a route for food to bypass the stomach, duodenum, and part of the jejunum is created. The surgeon staples off most of the stomach to create a small pouch, and then attaches this pouch directly to the small intestine. This results in both a restriction of the quantity of food that can be eaten at one time and a reduction in the amount of energyyielding and other nutrients absorbed from the food.

3. Criteria include either (a) BMI of 40 or more (45 kg/100 lbs overweight for men, or 37 kg/80 pounds for women) or (b) BMI of 35–39.9 and one or more serious comorbidities, plus an understanding of and willingness to comply with the required lifestyle changes postsurgery.

4. $20 000 to $25 000 (U.S.)

5. This depends on the patient’s province of residence and extended health insurance provider.

6. Short term: bleeding, infection, leaks where intestines are sewn, embolism; long term: hernia, strictures, “dumping syndrome,” anemia due to iron or vitamin B12 deficiencies, osteoporosis due to reduced calcium absorption.

7. Patients must take vitamin/mineral supplements to prevent deficiencies.

8. Many patients lose up to half their excess weight 18 to 24 months after surgery, and many maintain a weight loss of 60–70 percent of their excess weight for 10 years or more. This weight loss may relieve comorbid conditions such as hypertension, diabetes, and sleep apnea.

9. Answers will vary.

Worksheets 93, 94, 95, and 96 Answers will vary.

Worksheet 97: Chapter 9 Crossword Puzzle1. weight cycling

2. bariatrics

3. sibutramine

4. hypertrophic

5. fad diets

6. benzocaine

7. diuretic

8. epidemic

9. orlistat

10. hyperplastic

4 Source for answer key: National Institute of Diabetes & Digestive & Kidney Diseases. Weight-control Information Network: Gastrointestinal Surgery for Severe Obesity. Accessed 26 Oct. 2009 & 8 Nov. 2006 from: http://win.niddk.nih.gov/publications/gastric.htm.


http://win.niddk.nih.gov/publications/gastric.htm


Worksheet 98: Learn to “Shape Up” (Internet Exercise)1. False

2. True

3. True

4. a, b, d

5. a

6. a

7. a. 39 grams, b. 56 grams, c. 42 grams, d. 61 grams

8. False

9. a

10. a. Handful, b. 6 stacked dice, c. Tennis ball, d. Thumb

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WO R K S H E E T AC T I V I T I E S

Worksheet 91: Weight Management Medications

Medication Classification Clinical Indication Monitoring Aspects

Megestrol acetate (Megace)

Orexigenic agent

Dronabinol (Marinol)

Orexigenic agent

Sibutramine hydrochloride monohydrate (Meridia)

Norepinephrine, serotonin and dopamine inhibitor

Orlistat (Xenical, alli)

Lipase inhibitor

For each of the medications listed above, look up both the clinical indications and the monitoring aspects associated with patients taking this drug for their respective weight management issue.

After you have found the information, consider the following questions:

1. Which government agency is involved in the regulation of these medications?

2. Is ongoing monitoring required for the use of these medications?

3. What adverse effects could occur if a patient is taking these medications?

4. How would you evaluate whether the patient is improving with respect to treatment?

5. How expensive are the medications?



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Worksheet 92: Clinical Application—Bariatric Surgery

Consider the following scenario: Someone told you that he was considering having a “gastric bypass” and asked you to explain to him exactly what that meant in terms of the surgical procedure and nutritional management. When considering these questions, identify the resources that are available to people on the Internet.

1. How would you go about finding out about the surgical procedure?

2. What is meant by the term “gastric bypass”?

3. What criteria are used to determine if an individual should have this type of procedure?

4. How much does this procedure cost?

5. Will insurance cover the procedure?

6. What are the complications associated with this type of procedure?

7. What type of nutritional management will occur postprocedure?

8. What will be the longterm effects of this type of procedure?

9. First, think of the answers that would be provided by a healthcare provider to a patient and secondly, think of the answers that a patient might obtain independent of a healthcare provider. How would the answers differ? How would you determine the resources’ scientific reliability and validity?



Worksheet 93: Evaluation of a Commercial WeightLoss Program

1. Select a commercial weightloss program. Describe the food program promoted by the organization. Is the program flexible enough to allow people with different foodways and lifestyles to use it successfully? Is it adaptable and easy to follow? Does it provide variety? Does the program provide for weight maintenance after goal weight is achieved?

2. Describe how the plan works. Does it require substantial registration fees, mandatory purchase of various items or foods, attendance at a minimum number of meetings?

3. Evaluate whether the plan offers a nutritionally sound way to lose weight. What characteristics make it sound or unsound?

4. Attend a group meeting of the program, if possible. Describe any “case histories” you might overhear or learn about and your impressions of them. Do the stories sound authentic? Do they sound as though the person’s weight loss was achieved sensibly? Do they present facts? Do they contain any “magic bullets”?

5. Describe your overall impressions of the meeting, telling whether they were positive or negative and why. If you had a weight problem, would you consider membership in this organization?

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Worksheet 94: Eating Attitudes Test

Answer these questions using the following responses:

A = Always U = Usually O = Often S = Sometimes R = Rarely N = Never

Response Score*_____ _____ 1. I am terrified about being overweight.

_____ _____ 2. I avoid eating when I am hungry.

_____ _____ 3. I find myself preoccupied with food.

_____ _____ 4. I have gone on eating binges where I feel that I may not be able to stop.

_____ _____ 5. I cut my food into very small pieces.

_____ _____ 6. I am aware of the calorie content of the foods I eat.

_____ _____ 7. I particularly avoid foods with a high carbohydrate content.

_____ _____ 8. I feel that others would prefer if I ate more.

_____ _____ 9. I vomit after I have eaten.

_____ _____ 10. I feel extremely guilty after eating.

_____ _____ 11. I am preoccupied with a desire to be thinner.

_____ _____ 12. I think about burning up calories when I exercise.

_____ _____ 13. Other people think I am too thin.

_____ _____ 14. I am preoccupied with the thought of having fat on my body.

_____ _____ 15. I take longer than other people to eat my meals.

_____ _____ 16. I avoid foods with sugar in them.

_____ _____ 17. I eat diet foods.

_____ _____ 18. I feel that food controls my life.

_____ _____ 19. I display selfcontrol around food.

_____ _____ 20. I feel that others pressure me to eat.

_____ _____ 21. I give too much time and thought to food.

_____ _____ 22. I feel uncomfortable after eating sweets.

_____ _____ 23. I engage in dieting behaviour.

_____ _____ 24. I like my stomach to be empty.

_____ _____ 25. I enjoy trying new rich foods.

_____ _____ 26. I have the impulse to vomit after meals.

_____ Total score*Scoring:3 for never, 2 for rarely, 1 for sometimes, 0 for always, usually and often. Total scores under 20 points indicate abnormal eating behaviour.

Source: J. A. McSherry, Progress in the diagnosis of anorexia nervosa, Journal of the Royal Society of Health 106 (1986): 8–9. (Eating Attitudes Test developed by Dr. Paul Garfinkel.)



Worksheet 95: Exploring Eating Habits

To explore your eating habits, check all the answers that describe your food intake patterns. Then, consider possible areas for improvement.

When do I usually eat?

_______ At mealtime.

_______ While studying.

_______ While preparing meals or clearing the table.

_______ When spending time with friends.

_______ While watching TV or participating in other activities.

_______ Anytime.

Where do I usually eat?

_______ At home at the kitchen or dining room table.

_______ In the school cafeteria.

_______ In fastfood places.

_______ In front of the TV or while studying.

_______ Wherever I happen to be when I’m hungry.

Why do I usually eat?

_______ It’s time to eat.

_______ I’m hungry.

_______ Foods look tempting.

_______ Everyone else is eating.

_______ Food will get thrown away if I don’t eat it.

_______ I’m bored or frustrated.

Changes I want to make:

Source: U.S. Department of Agriculture, Dietary Guidelines and Your Health: Health Educator’s Guide to Nutrition and Fitness (Washington, DC, US Government Printing Office, 1992).

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Worksheet 96: Exploring Food and Activity Choices

Does your BMI fall between 18.5 and 24.9? If so, you may want to maintain your weight. If not, you may need to gain or lose weight to improve your fitness and health. Determine whether these food and activity choices are typical of your lifestyle.

Food and Activity Choices Frequency per Week

Promote weight gain:

Drink plenty of juice.

Eat energydense foods.

Eat large portions.

Eat peanut butter crackers between meals.

Eat three or more large meals a day.

Promote weight loss:

Drink plenty of water.

Eat nutrientdense foods.

Eat slowly.

Eat small portions.

Limit snacks to healthful choices.

Limit television watching.

Participate in physical activity.

Select lowfat foods.

Share a restaurant meal or take home leftovers.

On average, do your lifestyle choices promote weight gain, weight loss, or weight maintenance?



Worksheet 97: Chapter 9 Crossword Puzzle

1

2

3

4 5

6

7

8

9

10

Across Down

6. Anesthetizes the tongue, reducing taste sensations

7. A drug that promotes water excretion; popularly, “a water pill”

8. The appearance of a disease or condition that attacks many people at the same time in the same region

9. A drug used in the treatment of obesity that inhibits the absorption of fat in the GI tract

10. Obesity due to an increase in the number of fat cells

1. Repeated cycles of weight loss and gain, popularly called the ratchet effect or yoyo effect of dieting

2. Field of medicine specializing in the treatment of obesity

3. A drug used in the treatment of obesity that slows the reabsorption of serotonin in the brain, thus suppressing appetite and creating a feeling of fullness

4. Obesity due to an increase in the size of fat cells

5. Popular eating plans that promise quick weight loss

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Worksheet 98: Learn to “Shape Up” (Internet Exercise)

Go to the following website to answer questions 1–10: http://www.shapeup.org/shape/sud10index.php. Do NOT close the window until you are finished answering all of the questions. You will have to click on each step of the sequence process including the introduction.

1. The use of salad dressing contributes to weight loss.a. Trueb. False

2. Research indicates that the body perceives calories associated with fluid intake differently than those associated with food intake.a. Trueb. False

3. Even though club soda and seltzer are calorie free, seltzer is a better liquid source because it contains less sodium.a. Trueb. False

4. What are the key practices associated with weight loss? Select all that apply.a. Selfmonitoringb. The reward of positive behaviorsc. Eating less foodd. Having ample support

5. In order to maintain weight loss, the best option is to _____.a. include exerciseb. reduce caloriesc. eat lessd. only drink water

6. Looking at Table 1 in Step 5, how many calories (kcal) does Ralph need each day in order to maintain his weight?a. 2208b. 1838c. 2338d. 1535

7. Looking at Table 1 on Step 6, match the pertinent fat gram limit information for the selected people.a. Susan _____ 39 gramsb. Ralph _____ 42 gramsc. Edna _____ 56 gramsd. Bob _____ 61 grams

8. In order to evaluate one's resting metabolic rate, the measurement should be taken following consumption of a light meal.a. Trueb. False

(Worksheet continues on the next page)


http://www.shapeup.org/shape/sud10index.php


9. According to the information presented on this website, a person who eats a cheeseburger, small fries, and a small Coke from McDonald’s ingests:a. 690 calories (kcal)b. 460 calories (kcal)c. 500 calories (kcal)d. 490 calories (kcal)

10. Match the food item with the common item that best represents an adequate serving size.a. Nuts _____ Thumbb. Cheese _____ 6 stacked dicec. Fruit _____ Handfuld. Salad dressing _____ Tennis ball

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Chapter 9 Weight Management: Overweight, Obesity, and ...s3.amazonaws.com/prealliance_oneclass_sample/lz68wDblLO.pdfEnriched Instructor’s Manual to Accompany Understanding Nutrition,