Nutrition
What type of diet should be avoided in patients on SGLT2i's and why?
Keto - increased risk of ketoacidosis, also caution for hypoglycemia on SGLT1i and with insulin
What is recommended minutes of moderate vs vigorous intensity exercise per week for general health and weight loss? What is considered moderate vs vigorous?
150min mod intensity , for weight loss 200-300min mod/week
75min vigorous , for weight loss 150min vigorous
+2-3d/wk of 20minute min anaerobic strength training, preserves lean muscle mass and improves resting metabolism
moderate: 50-69% max HR for age, can talk but not sing, Brisk walk, hiking, light cycling
vigorous: 70-85% max HR for age, can say short phrases only, Jogging, HIIT, fast cycling, rowing, lap swimming, competitive sports, dancing/zumba
What is average weight loss seen with semaglutide at max dose after 1.5 years in STEP 1 trial in adults?
What about with teens in STEP TEENS trial?
adults: 15-16% (higher with ILI)
teens: 15%, 16% reduction in BMI in teens
What is the average % weight loss seen after sleeve gastrectomy vs RYGB?
SG:25-30%
RYGB:30-35%
How should you advise patients after bariatric surgery (RYGB in particular) to prevent dumping syndrome?
Increased protein intake, protein before carbs in a meal to prevent exaggerated insulin release from rapid undigested carbs into small bowel and rapid glucose absorption
What type of eating struggle is Qsymia (phentermine/topiramate) most helpful for ?
What type of eating struggle is Contrave (Bupropion-Naltrexone) most helpful for?
qsymia- binge eating
contrave- food cravings/emotional eating (works on hypothalamic appetite path as well as on hedonic/emotional eating paths with limbic system
What is recommended caloric deficit (compared to estimated basal needs for age/gender) for successful weight loss?
minimum 500kcal/day, which typically results in a loss of 1-2lbs/wk and >5% weight loss over 6mo
What is most helpful for insomnia, having the same bedtime every night or the same wake time? What should a patient do if they wake during the night to help with going back to sleep?
Same wake time, not bedtime, go to bed when sleepy
Get up after 20min don't just lay there! Go do something relaxing/mundane until sleepy then back to bed to retrain
Which weight loss medications are approved in teens 12 and up and what is average weight loss seen with each?
1.GLP-1 RAs: Semaglutide (15% BMI reduction) and Liraglutide (5% BMI reduction)
2.Qsymia (Phentermine/Topiramate) (10% BMI reduction)
What substance use disorder risk is increased after bariatric surgery?
Alcohol use disorder - due to rapid alcohol absorption and heightened effect, also addiction transference of food to alcohol
In a patient with neuropathy symptoms following bariatric surgery which vitamin deficiencies should be checked?
B12, B1 (thiamine), B6 (pyridoxine), copper
List at least one strict contraindication to GLP-1 RAs and one relative contraindication.
Strict: fam hx of medullary thyroid cancer or MEN2, pregnancy
Relative: severe gastroparesis, increased risk of or h/o pancreatitis
Which type of diet has been shown to have benefit in reversal of MASLD independent of weight loss?
Mediterranean diet
List 3 behavioral techniques that can help with weight loss success?
1.Self-monitoring (weekly weigh in, food logging on MFP or other app)
2.Goal setting - SMART goals
3.Detailed SMART goal nutrition or exercise prescriptions (can have both positive and negative goals)
4.Stimulus control - changing environment, i.e. reducing cues for overeating/inactivity -Limiting unhealthy tempting foods in the home, changing size of plates/containers for portion control, increase cues for healthy eating/activity - setting behaviors and habits and schedules to assists with adherence to exercise, laying out clothes before bed, setting healthy foods in visible prominent spots, meal planning/prepping
5.Problem Solving - identifying barriers and problems
6.Positive Reinforcement, Challenging Negative Thoughts
7.Relapse Prevention - validate normalcy of slips/setbacks, strategize for barriers/situations
8.Mindful eating - eating slowly, eating with others never alone, noticing and enjoying the food
What is average weight loss on highest dose of tirzepatide (approved for adults only) in SURMOUNT-1 and 3 trials?
20-25% (higher end when combined with ILI)
The mortality risk from bariatric surgery is similar to that of what common surgery?
Cholecystectomy
Which vitamin deficiency can be seen within days to weeks after bariatric surgery? Hint: it can cause severe neurologic and cardiac manifestations..
B1 (thiamine), the quickest to deplete, can see Wernicke's (nystagmus/ataxia) quickly after surgery if malnourished and not taking vitamins
vs B12 takes months to years to develop deficiency and manifestations...
Which beta-blocker is the most weight neutral?
Carvedilol
What is the recommended g/kg/day of protein intake during active weight loss both for adults and adolescents?
1.2-1.5g/kg of ABW (adjusted body weight)/day, higher end for sarcopenic obesity/elderly or athletes
Calculating based on actual body weight in patients with obesity can overestimate needs and increase caloric intake with this degree of protein intake.
What is average weight loss seen with exercise alone at goal of 150min of moderate intensity or 75min of vigorous intensity exercise per week?
3-5%, 4-10lbs over 12 months
With 225min/wk plus can reach 7-8% or higher
Which medication has approval and benefit to help offset antipsychotic induced weight gain and which vitamin deficiency should you monitor for when chronically used?
Metformin
Vitamin B12 deficiency
What is youngest age that bariatric surgery is approved in the pediatric population? What is BMI criteria indication for bariatric surgery?
13yo
Class 3 obesity: BMI >140%tile of 95%tile (>99%tile on older charts)
Class 2 obesity: BMI >120%tile of the 95%tile (97-99%tile on older charts) with comorbidities
What vitamin deficiency seen after bariatric surgery can cause anemia (typically macrocytic), neutropenia, myeloneuropathy, ataxia, stocking & glove paresthesias or impaired wound healing?
Copper
What is average amount of weight regained seen in patients who were on semaglutide for 68 wks then stopped after being off semaglutide for 1 year?
approx 2/3 of weight loss was regained (STEP-1 Trial), maintained approx 6% weight loss
men: 38g/day
women: 25g/day
Teens: similar goals
Children: AAP age in years + 5g/day then adult amounts after 15yo
In addition to cardio when pursuing weight loss what is recommended amount of anaerobic/strength exercise per week?
2-3 days/week
How long before pregnancy should a GLP-1 or GLP-1/GIP RA be dicsontinued?
2 months
List 3 possible long term complications from RYGB?
1.Peptic ulcer
2.Marginal/anastomotic ulcers (at GJ anastomotic site due to acid injury to acid-naive jejunum, mostly caused by NSAIDs, H. pylori, smoking) - epigastric pain, N/V, UGIB 3-6mo post-op, dx with EGD
2.Stenosis/stricture - dysphagia, solid food intolerance 3-6mo post-op, dx with upper GI barium
3.Malnutrition
4.Dumping syndrome (in first year post-op)
Which diabetic neuropathy medication is the most weight neutral and which should be avoided if weight loss is desired?
1.Cymbalta
2.Pregabalin/Gabapentin
What is the only FDA approved medication for binge-eating disorder in adults?
What are other medications with benefit and used off label for binge eating disorder?
1.Vyvanse
2.Topamax, Qsymia (Phentermine-Topiramate), SSRIs (Zoloft best evidence for NES, Prozac), Bupropion, GLP-1 RAs
Name at least 1 reason for the weight loss benefit of consuming adequate higher protein goals?
What is the recommended g/kg/day of protein intake recommended during active weight loss?
1.Increases thermogenesis (Thermic Effect of Food) ie burns more calories to digest (thus ultimately increases total energy expenditure)
2. increases satiety, digested slower, can lead to reduction in total calorie intake due to this
3.stimulates muscle anabolism, increases lean muscle mass (which can have some effect on increasing REE)
Part B: ~1.2g/kg/day (ideally based on ABW in setting of obesity) vs typical RDA of 0.8g/kg/day
What contributes to weight loss plateaus or weight regain after weight loss?
Metabolic adaptation - non-resting energy expenditure decreases by about 20-30% due to increase in skeletal muscle efficiency
Also resting energy expenditure/metabolism slows. Also some increase in appetite hormones (grehlin)
This is why increased exercise during weight loss maintenance phase is so helpful and necessary.
Not permanent, may last months to a year, may need ~200kcal/day less that what is expected for new body mass/weight for a while and increase exercise goals to >200min/wk
How long prior to endoscopy and surgery/anesthesia should a GLP-1 RA be held?
1-2 weeks to ensure proper prep and for anesthesia to avoid aspiration
What is the most common complication of sleeve gastrectomy?
GERD
Does HRT in post-menopause women help with weight loss?
No, however may minimize central adiposity redistribution and increase lean muscle mass
List 3 contraindications to Phentermine-Topiramate (Qsymia).
1.Pregnancy (both contraindicated)
2.Substance abuse (phentermine)
3.Kidney stones (topiramate)
4.Uncontrolled depression (topiramate) or uncontrolled anxiety (phentermine)
5.Recent CAD (Phentermine)
6.Glaucoma (phentermine can ause acute angle closure glaucoma)
HTN is NOT a contraindication, actually Qsymia shown to lower BP in studies, but would take caution with uncontrolled HTN until under good control.
What are AHA recommended limits to added sugars per day in average adult diet (in g/day)?
Child <2yo?
Child >2yo?
Adult: men<37.5g, women <25g (one 12 oz coke 39g)
Child >2yo: <25g/day (one 12 oz gatorade hits this)
Child <2yo: 0g/day
Which appetite stimulating hormones are elevated in patients with OSA or chronically poor quality/amount of sleep (particularly <6h)?
Increased grhelin and cortisol, both of which stimulate appetite pathways in brain (leptin - satiety hormone is decreased)
For a patient on a GLP-1 RA who has 3-4 week interruption despite previously tolerating highest dose, what dose should you restart them on?
Lowest dose and re-uptitrate on monthly basis due to return of significant gastroparesis effect and potential for significantly heightened GI side effects
How long should a female patient wait to conceive after bariatric surgery?
12-18 mo min, mostly due to nutritional deficiency concerns on fetal development
What vitamin deficiency seen after bariatric surgery can cause chronic diarrhea, alopecia, dysgeusia, anosmia, or even ED in males?
Zinc
What are 3 contraindications to Contrave?
1. Uncontrolled HTN (Wellbutrin)
2.Opioid use (naltrexone)
3.Seizures or high risk for seizures (eating disorder, heavy alcohol use and risk for withdrawal-Wellbutrin)
4.Pregnancy
List at least 2 risks of VLCD (<800kcal/day)
Gallstones, gout attacks, nutritional deficiencies
Patients with OSA or poor quality sleep have lower levels ___ and higher levels of ____ which can contribute to weight gain or difficulty losing weight.
lower leptin, higher ghrelin
also have higher cortisol
Studies revealed 15% difference in levels of these hormones in 5 vs 8h of quality of sleep
Which medications for weight loss are known to potentially be teratogenic?
Adipex (phentermine)
Contrave (Naltrexone component)
GLP-1 RA not known to be teratogenic but for now contraindicated in pregnancy
What is the most common vitamin deficiency following sleeve gastrectomy?
B12
due to cutting out 80% of stomach, parietal cells that make IF, cofactor for B12 absorption although it is absorbed mostly in ileum
What vitamin deficiency that can cause persistent diarrhea and cardiomyopathy can be seen on a long-term keto diet due to increased fatty foods often low in this vitamin and often restricts fruits/grains/legumes that are high in this vitamin?
Selenium
Which weight loss medication might by helpful for those who struggle with high soda intake due side effect of altering the taste of soda?
Topamax (or Qsymia)
What positive effect does low carb diet have most significantly on lipid profile? Increase in ____ and decrease in ____.
Keto low carb in particular negatively can cause an increase in ___ but positively has the same effect as above.
keto- increase in LDL
What serving size of chia seed or ground flaxseed provides recommended daily needs of 2g/day ALA (omega 3 fatty acid) that can help with insulin resistance, lowering LDL/TG, satiety, constipation, gut microbiome?
Chia - 1 Tbsp/day
Flaxseed (must be ground to be absorbed) - 1-1.5 Tbsp/day
Best to give 1Tbsp of each - provides 10-12g/fiber
What is the primary MOA of GLP-1 RA and also GLP-1 RA/GIP? Where do these work?
Stimulates POMC/CART pathway in hypothalamus (anorexigenic pathway)
Also increases satiety by delaying gastric emptying but this effect wanes with time, primarily from brain pathway effect.
What is the most common vitamin/mineral deficiency after RYGB?
Iron, absorbed in duodenum
Deficiency of this vitamin can lead to peripheral neuropathy and MICROcytic anemia?
B6 (pyridoxine) think B6 is smaller than B12 thus micro vs macrocytic anemia
Which depression medications are weight neutral and best choices in a patient with obesity or weight concerns?
Wellbutrin (weight loss benefit)
SSRIs: Fluoxetine (Prozac), Sertraline (Zoloft)
Buspar
SNRIs: Desvenlafaxine (Pristiq), Cymbalta
Low fat diets have what effect on lipid profile? Positive effect: Decrease in ____ and negative effect of decrease in: ____.
Decrease in LDL and also possibly HDL
Therefore even on low fat diet, recommendation is to focus on healthier poly/monounsaturated fats and still get % of calories from fat.
What hormones are secreted by adipocytes and what effect do they have on the body? List 2.
1.Resistin - increases insulin resistance
2.Interleukins, prostaglandins, cytokines - pro-inflammatory
3.Estrogen - hence increased breast and endometrial ca risk
4.Angiotensinogen - increase BP
5.PAI-1: inhibits fibrinolysis- thus increases risk of blood clots
What medication used for weight loss should be used in caution in combo with Metformin due to increased risk of type B lactic acidosis?
Topamax (can still be used but NOT if other risk factors i.e. age >65, contrasted studies, renal failure, hypoxia, significant alcohol use)
What are the main hormonal changes from RYGB and SG that lead to immediate weight loss and for RYGB immediate BG reduction?
RYGB: increased GLP-1 RA due to intestinal release when carbs given they avoid initial breakdown in duodenum
SG: decrease in Ghrelin secreted from gastric parietal cells
Increasing this nutrient in the diet can help with weight loss via increasing satiety. This nutrient also has a potential positive effect on reducing LDL.
Fiber
Which weight loss medication can decrease efficacy of some forms of contraception and also is teratogenic and associated with cleft lip/palate?
What are UPT testing recommendations and specific contraception recommendations if using this medication?
Qsymia (Topiramate component)
Do UPT before starting and monthly (many do not do this in practice depending on risk of ea patient, but this is REMS recommendation)
Contraception: IUD, nexplanon, can decrease efficacy of COC/patch/depo
What is the AHD recommendation on the max % of calories consumed from saturated fat in a day? What is the recommendation of % of total calories/day from fat (healthier fats) to avoid unhealthy consequences (i.e. lowering of HDL)?
1.<7% from saturated fat
2.20-40% from fat - poly/monounsaturated preferentially
(Fat is 9kcal/g of fat to put this in more practical food label monitoring terms for patients, i.e. for avg calorie goal diet of 1800-2,000cal/day means limiting saturated fat to ~15g/day)
List 3 plant-based protein sources offering >5g of protein/serving size?
1.Lentils-18g/cup
2.Beans-kidney, pinto, black (15g/cup), white, garbanzo/chickpeas (18-20g/cup) -
3.Edamame-20g/cup
4.Soy (tofu-20g/1/2 block)
5.Nuts and seeds - 5-10g/serving (handful or 1/4c of most nuts 5-7g, highest in order: hemp seed, pumpkin seed, chia, flax, sunflower seeds, peanut, almond, pistachio, cashew, walnuts)
6.Whole grains - quinoa (8g/cup cooked), hemp seed, buckwheat (i.e. soba noodles), brown rice (6g)
7.Not plant-based, but greek yogurt-20g/cup
When on COC for contraception and taking a GLP-1 RA, for how long after each dose increase should back up barrier contraception methods be used due to gastric emptying effect decreasing efficacy of COC?
4 wks after each dose increase
List 3 contraindications to sleeve gastrectomy?
Which eating disorder is associated with morning anorexia, skipping breakfast, evening hyperphagia and consuming >25% of daily calories after evening meal and nighttime awakenings to eat (conscious of this)? Which hormone may be elevated in these patients exacerbating symptoms? Increasing which macronutrient in the diet can best help this syndrome?
1.Night Eating Syndrome (vs SRED where there is no recollection of eating at night and associated with sedatives for insomnia)
2.Ghrelin is increased due to poor sleep
3.Increase protein, changing carb:protein ratio, less rebound hunger, EAT BREAKFAST high in protein
What is average weight loss seen with oral weight loss medications (Phentermine-Topiramate (Qsymia) vs Bupropion-Naltrexone (Contrave))? Bonus: Who would be most likely to benefit from each of these individually (i.e. type of eating patterns or other comorbidities)?
Qsymia- 10%, binge eating, comorbid migraines
Contrave - 6-8%, strong food cravings, tobacco use/desire for cessation, fear of weight gain with quitting