WEIGHT LOSS, EATING DISORDERS AND OBESITYDr. Maria Honolina S Gomez, MD, FPCP, FPSEM, FACE Section of Endocrinology, Diabetes and Metabolism

By: Thea C. Marcelo Sec C 2014

LEARNING OBJECTIVES:1. To discuss the anthropometric measurements2. To differentiate VOLUNTARY from INVOLUNTARY

weight loss3. To define and describe eating disorders

EQUIPMENT Standing platform scale with height attachment Skinfold thickness calipers Measuring tape, non-stretching Infant scale Recumbent measuring

device (for infant) Stature measuring device

(for children)

ANTHROPOMENTRIC MEASUREMENTS

Height or length Weight Mid-upper arm

circumference (MAC) Demi-span or arm span Knee height Sitting height Skinfold thickness Head circumference

Height

Weight

- A portable scale with a 125 kg maximum capacity and a +/- 100g error margin is used

- Individuals remove shoes and heavy cloths prior to weighing

- What to do if not able to weigh in properly? Assess in change of clothing size Corroborate weight loss with relative or

friend The numerical estimate of weight loss

provided by the patient are suggestive enough of true weight loss

Knee Height- Correlated with stature- The preferred method in estimating height in

bedridden patients

- Measured using a sliding broad-plane caliper- While lying supine, asked to bend both left knee

and ankle at 90°. Fixed blade under the heel of left foot while sliding blade pressed down against thigh about 5.1cm proximal to knee cap.

- Shaft of caliper in line with long bone (tibia) in lower leg and over ankle bone (lateral malleolus).

- Locking lever pushed away from blades to hold measurement and read thru viewing window to nearest 0.1cm.

- 2 measurements made in succession which should agree within 0.5cm.

Assessing Height and Weight Current weight Current height Usual weight Desirable body weight: Tanhauser’s or Hamwi’s

method % desirable body weight : current weight x 100

desirable body wt

% usual weight : current weight x 100

Usual wt % weight change : (usual wt – current wt) x 100

Usual wt

Adjustment for Amputation- Subtract the percentage weight contributed by

amputated body parts

Trunk without limbs – 42.7%Entire upper extremity – 6.6%

Hand – 0.8%Forearm – 2.3%Upper arm – 3.5%

Entire lower extremity – 18.7%Foot – 1.8%Lower leg – 5.3%Thigh – 11.6%

Paraplegia – subtract 5-10% from calculated DBWQuadriplegia – subtract 10-15% from calculated DBW

Arm Span- Procedure: face away form wall, with back and

buttocks touching, the arms are stretched out horizontally. Measure from tip ( 3rd finger) to the other

- Results: Arm span = heightArm length = arm span – shoulder width

- Exemptions: Marfan’s syndrome

Sitting Height- Stretch stature method- Maximum distance: vertex to the base of sitting

surface- Seat subject on a measuring box or level platform

(of known height) with their hands resting on their thighs

- Instruct subject to take and hold deep breath- Place headboard firmly down the vertex, crushing

hairs as much as possible- Ensure not to contract gluteal muscles or push with

legs- Record measurement at the end of deep-inward

breath – record at nearest 0.1cm

Method for determining frame size1. Elbow Breadth measurement

- Extend right arm and flex elbow at 90°- Thumb pointing up with palm turned laterally- Face patient and put caliper between two most

prominent bones of elbow2. Wrist Circumference

- A person’s height and the measure of his wrist determines body frame size

- Determining body frame size with wrist circumference ratio:

HEIGHT (cm) / WC (cm)

Frame Size Ratio for Men Ratio for WomenSMALL <9.6 <9.9MEDIUM 9.6 - 10.4 9.9 – 10.9LARGE >10.4 >10.9

Body Mass Index- Measure of body fat in adults to help assess

whether one is at risk of weight-related problems BMI = Wt in kg / Ht in m2

Do NOT apply to children, pregnant women, people with muscular build (little body fat) eg. athletes

Waist Circumference- The plane between umbilical scar and inferior rib

border- NO holding your belly in!- Midway between uppermost border of iliac crest

and lower border of costal margin (ribcage) - Tape is snug but does not compress skin

MEN WOMENWHO Asians >35 in (90cm) >31 in (80cm)WHO Caucasians >40.0 >35.0

Hip Circumference- Stand erect with weight evenly distributed on

both legs, legs slightly parted, with arms resting by the side, making sure not to tense gluteal muscles

- HC measured from the maximum perimeter of buttocks

- Tape not too tight or too loose, lying flatWaist-Hip Ratio

- Measures proportion by which fat is distributed around the torso

- WHO: >0.7 for women >0.9 for men

- Apple type more susceptible to DM, CV disease, ovarian and prostate CA more wt above waist

- Pear type more wt below waist (better)

NUTRITIONAL STATUS1. Triceps Skin fold

- Person stand upright with arms hanging down loosely

- Skinfold pulled away from muscle and measured with calipers, taking a reading 4 secs after calipers are released

- The measuring point is halfway between olecranon process of the ulna and acromion process of scapula

- Decreased TSF = decreased fat stores due to long term undernutrition

2. Mid-upper Arm Circumference- Circumference of upper arm at the same

midpoint, measured with non-stretchable tape measure

- Used to determine subcutaneous or fat loss- Reflects the skeletal mass status of patient

MICRONUTRIENTS: Clinical Indications Pallor of palms or inside of eyelids and mouth

Iron deficiency Anemia Night blindness (inability to see in low light)

Vitamin A deficiency

Bitot’s spot (spots on whites of eyes) Vitamin A deficiency

Goiter (enlargement of thyroid) Iodine deficiency

Hair fall in women Zinc deficiency

Physical Findings of Nutritional Deficiencies 1. Vitamin C

- Corkscrew hairs - Unemerged coil hairs - Petechiae (esp perifollicular) - Swollen retracted gum bleed

2. Vitamin C and A - Follicular hyperkeratosis

3. Vitamin C and K - Purpura

4. Niacin - Pigmentation, scaling of sun exposed areas

5. Protein - Easily pluckable hair - Flag sign (transverse hair depigmentation) - Sparse hair (together with zinc) - Transverse ridging of nails - Cellophane appearance - Cracking (flaky paint or crazy pavement

dermatosis) - Parotid enlargement also consider bulimia

6. CHON, Vit C, Zinc - Pour wound healing - Decubitus ulcer

7. Vitamin A - Night blindness - Papilledema

8. Riboflavin, Pyridoxine, Niacin - Angular stomatitis - Cheilosis (dry, cracking ulcerated lips)

9. Riboflavin, Pyridoxine, Niacin, Folate, B12 - Glossitis (scarlet, raw tongue)

10. Riboflavin, Niacin, Folate, B12, Protein, Iron - Atrophic lingual papillae (slick tongue)

11. Zinc - Hypoeusethesia, hyposmia

12. Protein, Thiamine - Edema

13. Thiamine (Wet Beriberi), Phosphorous, Protein, Vit A

- hepatomegaly

WEIGHT LOSS- It is the reduction of the total body weight due to a

near loss of fluid body fat or adipose tissue and/or lean mass usually bone mineral deposits, muscle, tendon and other connective tissue.

Significant Weight Loss1.0% - 2.0% in one week5.0% in one month7.5% in 3 months10.0% in 6 months

4.5 Kg ( 10 lb), or more than 5% of baseline body weight over a period of 6-12 months

HPI: Weight Loss Total weight loss: compared with usual weight,

time period (sudden or gradual, desired or undesired)

Desired weight loss: eating habits, diet plan used, MNT, food preparation, food group avoidance, exercise pattern, target goal

Undesired weight loss: anorexia, vomiting, diarrhea, frequent urination, excessive thirst, change in lifestyle, stress levels

Preoccupation with oneself, unusual food restrictions or cravings, laxative abuse, induce vomiting, amenorrhea, excess exercise

Medication: chemotherapy, OHA, insulin, fluoxetine, diuretics, nonprescription appetite suppressants, herbal supplements

Major causes of Weight Loss Voluntary (desired)

- May not be a matter of concern in an overweight patient who is dieting but can be a manifestation of psychiatric illness

1. Treatment of obesity Sibutramine – causes heart disease

Rimonaban – suicidal tendencies2. Anorexic drugs

Amphetamine Thyroid hormone

3. Anorexia nervosa & Bulimia4. Distance runners, models, ballet dancer,

gymnasts

Involuntary (undesired)- With decrease or increase appetite is nearly

always a sign of a serious medical or psychiatric illness

1. With increased appetite- Hyperthyroidism (Grave’s)

Hyperdefacation Heat intolerance

- Uncontrolled Diabetes Uncontrolled - blood glucose greater

than 180mg (renal threshold for glucose) --> polyuria -->

Dehydration Weight loss is a sign of poorly

controlled DM- Malabsorption syndrome- Pheochromocytoma - marked increase in physical activity

2. With decreased appetite- Medical disorders

o Malignancy particularly GI, lung, lymphoma,

renal, prostrateo Endocrinopathies adrenal insufficiency (especially in

those chronic users of steroids; usual clue = fatigue)

o Chronic illness Severe heart, lung or kidney

diseases - cardiac cachexia (fatigue from eating, even walking), pulmonary cachexia (widened ICS, tripod), renal failure, nephrotic syndrome, chronic glomerulonephritis

o Infectious diseases hepatitis (fever followed by loss of

appetite), tuberculosis, fungal or bacterial diseases, chronic helminth infection

o COPD

o Gastrointestinal disease peptic ulcer diseases, diabetic

enteropathy, dysphagia, malabsorption, inflammatory bowel diseases, hepatitis, Zenker's diverticulum, paraesophageal hernia

- Psychiatric disorderso Depressiono Manic phase of manic-depressiveo Personality disordero Paranoid or delusional

- Chronic Drug Useo alcoholo opiateso amphetamineso cocaineso others (tropimate, exenatide,

metformin, serotonin uptake inhibitors, NSAID)

EATING DISORDERS- group of serious conditions in which a person is

preoccupied with food and weight that he/she can focus on little else.

- Types: Anorexia Nervosa Bulimia Nervosa Binge-eating Disorder

Red Flags to indicate Eating Disorder Skipping meals Making excuses for not eating Eating only “safe” foods, low in fat and calories Adopting rigid meals or eating rituals (cutting

food into tiny pieces or spitting food out after chewing)

Cooking elaborate food for others but refusing to eat it themselves

Collecting recipes Withdrawing from normal social activities Persistent worry or complaining about being fat A distorted body image such as complaining

about being fat despite being underweight Not wanting to eat in public Wearing baggy or layered clothing Repeatedly eating large amounts of sweet or

high-fat foods

Use of syrup of ipecac, laxatives, weight loss drug orlistat, or OTC drugs that can cause fluid loss, menstrual symptoms relief meds

Use of dietary supplements or herbal products for weight loss

Food hoarding Leaving during meals to go to use toilet Eating in secret Frequent checking in the mirror for perceived

flaws

Causes of Eating Disorders Biology

- People with first degree relatives – sibling or parents – with eating disorders maybe more likely to develop eating disorders

- Serotonin – a naturally occurring brain chemical, may influence eating behaviors

Psychological and Emotional health- Low self-esteem, perfectionism, impulsive

behavior and troubled relationships Society

- “Modern Western Culture Environment” cultivates and reinforces desire for thinness

- Success and worth = being thin- Peer Pressure

Risk Factors Being Female Age Family History Emotional disorders Dieting Transitions Sports, Work and Artistic activities

Complications Death Health Problems Multiple Organ Failure Depression Suicidal thoughts or behavior Absence of menstruation (amenorrhea) Bone loss Stunted growth Digestive problem Kidney damage Severe tooth decay High or low blood pressure

ANOREXIA NERVOSA

Criteria for Anorexia nervosa1. Restriction of food intake leading weight loss or

failure to gain weight2. Fear of becoming or gaining weight3. Distorted view of themselves and of their condition

Eg. Person thinking that he/she is overweight when they are actually underweight

Types of Anorexia Restricting type: stereotype of anorexia nervosa.

The person does not regularly engage in binge eating.

Binge eating/Purging type: The person regularly engages in binge eating and purging behaviors, such as self-induced vomiting and/or misuse of laxatives and diuretics. Similar to bulimia nervosa; however there is no weight loss criteria for bulimia.

Manifestations of Anorexia Refusal to eat and denial of hunger Intense fear of gaining weight A negative or distorted self-image Excessive exercise Flat mood or lack of emotion Irritability Fear of eating in public Preoccupation with food Social withdrawal Trouble sleeping Thin appearance

Physical Examination of Anorexia Soft downy hair present in the body (lanugo) Menstrual irregularities or loss of menstruation

(amenorrhea) Constipation Abdominal pain Dry skin Frequently being cold Irregular heart rhythms Low blood pressure Dehydration

BULIMIA NERVOSA- Episodes of binging and purging- A person typically eat a large amount of food in

short period of time- Try to rid himself of extra calories thru vomiting or

excessive exercise

- Normal weight or even slight overweight

Manifestations of Bulimia Eating until the point of pain or discomfort ,

often with high-fat or sweet foods Self-induced vomiting Laxative use Excessive exercise Unhealthy focus on body shape and weight Distorted, excessively negative body image Low self-esteem Going to the bathroom after eating or during

meals Feeling that you can’t control your eating

behavior Abnormal bowel functioning

Physical Examination of Bulimia Damaged teeth and gums Swollen salivary glands in cheeks Sores in throat and mouth Dehydration Irregular heartbeat Sores, scars or calluses in hands or knuckles Menstrual irregularities or loss of menstruation

(amenorrhea) Constant dieting or fasting Possibly drug or alcohol abuse

BINGE-EATING DISORDER- Person regularly eats excessive amounts of food

(binge) but don’t compensate with exercise or purging

- Eat when he/she is not hungry and continue eating even long after he/she is uncomfortably full

- After a binge, may feel guilty or ashamed, which can trigger new round of binging

- Normal in weight , overweight or obese

Symptoms may include: Eating

- To the point of discomfort or pain- Much more food during binge episode than

during normal snack or meal- Faster during binge episodes

Feeling that you’re eating behavior is out of control Frequently eating alone Feeling depressed, disgusted or guilty over amount

eaten

WEIGHT GAIN“They are sick that surfeit with too muchAs they that starve with nothing.”

– Shakespeare, Merchant of Venice

OBESITY- a metabolic disorder resulting from imbalance

between energy uptake and expenditure - Chronic - lifelong treatment required- Treatment controls do not cure disease- No short term solutions- Disease recurs after treatment is withdrawn

HPI: Weight Gain Total weight gain: time period, sudden or gradual,

desired or undesired, possibility of pregnancy Change in lifestyle: social changes, eating out,

meals eaten quickly, “on the go”, change in meal preparation, change in exercise patterns, stress level and alcohol intake

Medications: steroids, oral contraceptives, insulin antidepressants

Measures of Obesity 1. Ideal Body Weight (Filipinos) Male = 112lbs for first 5ft of height + 4 (x each

inch above 5) Female = 106lbs for first 5ft of height + 4 (x each

inch above 5) 2. Height 3. Weight Circumference

- Measured midway between lower border of costal margin and iliac crest

- South Asians o Male = >90cm o Female = >80cm

**Central obesity = apple more insulin resistant **Hip obesity = pear less insulin resistant

Energy Density of Food- Standard food portions have increased over the last

20 yrs.

Obesity in the Philippines- 1 out 5 people are overweight

- According to National Statistics Coordination Board, 26.6% of Filipinos are overweight, higher than 16.6% of 1993

- 5.2% of Filipinos are obese, that means 5 million Filipinos whose health are compromised

- There are 2x more obese females than males in Philippines

Contributors to Weight Genetics

- Body weight is 4-070% heritable Environment

- In utero- Food availability /consumption

- Physical activity

Obesity-related Comorbidities Respiratory: Obstructive sleep apnea, Bronchial

asthma, Pickwickian syndrome (obesity hypoventilation syndrome)

Malignant: endometrial, prostate, colon, breast, gallbladder and possibly lung cancer

Psychological: Social stigma and depression Cardiovascular: CAD, hypertension, LVH, cor

pulmonale, cardiomyopathy, atherosclerosis, pulmonary HPN

CNS: stroke, idiopathic intracranial hypertension, neuralgia paresthetica

Obstetric and perinatal: pregnancy-related HPN, fetal macrosomia, pelvic dystocia

Surgical: Increased surgical risks and post-op complaints, including wound infection, post-op pneumonia, DVT and pulmonary embolism

Pelvic: Stress incontinence

Gastrointestinal: Cholecystitis, Cholelithiasis, Non-alcoholic steatohepatitis (NASH), fatty liver infiltration, reflux esophagitis

Orthopedic: osteoarthritis, coxa vera, slipped capital femoral epiphysises, chronic lumbago

Metabolic : Type 2 DM, prediabetes, metabolic syndrome, dyslipidemia

Reproductive (in women): anovulation, early puberty, infertility, hyperandrogenism, polycystic ovaries

Reproductive (in men): Hypogonadotropic hypogonadism

Extremity: Venous varicosities, lower extremity venous and/or lymphatic edema

Physical Examination Cutaneous: intertriginous rashes from skin-to-skin

friction, hirsutism, acanthosis nigricans, skin tags, risk for cellulitis and carbuncles

Cardiac and respiratory: cardiomegaly and respiratory insufficiency

Abdominal: tender hepatomegaly due to hepatic fatty infiltration or NASH and striae

Extremities : joint deformities (eg. coxa vera), osteoarthritis, pressure ulcers, generalized and lipodystrophic fat distribution

Miscellaneous: reduced mobility and difficulty maintaining hygiene

Obesity Differential Diagnosis Type 2 DM Fatty Liver GERD Hirsutism Polygenic hypercholesterolemia Hypothyroidism Acromegaly Insulinoma Kallman syndrome and idiopathic

hypogonadotropic hypogonadism Generalized Lipodystrophy Polycystic ovaries (Stein-Leventhal syndrome) Cushing’s syndrome Adiposa dolorosa (Dercum disease) Partial lipodystrophy assoc. with localized

lipohypertrophy

DIAGNOSISLaboratory Studies Fasting Lipid panel Liver function test

Thyroid function test Fasting glucose and hemoglobin A1c (HbA1c)

Evaluation of Degree of Body fat BMI calculation, waist circumference, waist-hip

ratio Caliper-derived measurements of skinfold

thickness Dual energy radiographic absorptiometry (DEXA) Bioelectrical impedance analysis Ultrasonography to determine fat thickness Underwater weighing

APPROACHES TO OBESITY MANAGEMENTPrevention of further weight gain Behavioral Modification Diet

o Serving sizes- Use your hand to estimate portion sizes:- Fist = 1 cup- Palm = 3 ounces- Thumb tip = 1 teaspoon- Thumb = 1 ounce- Handful = 1 or 2 ounces snack food

o 1 Serving equals:- Carbohydrates = 15 g- Meat = 1 ounce- Fat = 1 teaspoon (5g)

Exercise Minimize offending drugs Weight loss medication Bariatric surgical interventions