ISSUES AT LARGE
From Scott and White’s The Adult Patient: Male and Female Issues, June 20-24, 2005
Veronica Piziak, MD, PhD, Professor of Endocrinology, Texas A&M University System Health Science Center
College of Medicine, College Station, Texas, and Chief of Endocrinology, Scott & White, Temple, Texas
| Introduction: recent studies show life advantage in being slightly overweight; intra-abdominal (visceral) fat
associated with more risk for disease than subcutaneous fat (unless person morbidly obese); most people
can lose ≈5% to 10% of body weight with conservative weight management, reducing risk for diabetes and
heart disease
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| Prevalence: ≈64% of population of United States overweight or obese; obese portion of population grew fastest
between 1980 and 2000; entire population moving up morbidity and mortality curve; children worldwide
becoming obese, even in countries previously involved in war; sociologic movement in Sweden to improve
food choices available to children
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| Clinical features of metabolic syndrome: ≥3 clinical features; waist circumference >40 in in men and in
women >35 in, high-density lipoproteins (HDL) low, serum triglycerides ≥150 mg/dL, hypertension, and fasting
glucose ≥100 mg/dL; lifestyle changes crucial in treating metabolic syndrome; patient with metabolic
syndrome at increased risk for myocardial infarction (MI)
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| Visceral fat: metabolically active fat; makes C-reactive protein, phosphatidylinositol (PI) 3-kinase, and numerous
inflammatory factors; patient not overweight but, with preponderance of visceral fat, still at risk for MI,
endothelial dysfunction, and breast cancer; abdominal fat—causes insulin resistance, increases triglycerides,
and produces inflammatory factors; measuring waist circumference equally as useful as waist-to-hip ratio in
evaluating for metabolic syndrome; possible to use dyslipidemia code (277.7) to proceed with thyroid and
glucose testing if patient shows signs of metabolic syndrome (ie, large waist circumference, hypertension)
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| Dyslipidemia and obesity: insulin directly affects kidneys; increased blood pressure (BP) causes sodium retention;
insulin resistance causes sympathetic nervous system to function at higher level, contributing to atherosclerosis
and dyslipidemia; diabetes results from insulin resistance; low-density lipoprotein (LDL)
atherogenically dense, more easily oxidized, and remains longer in blood stream
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| Successful weight reduction: patient must set realistic goal for weight loss; focus should be on improving
health, rather than attaining certain weight; 5% to 10% weight loss results in better health; weighing patient or
measuring waist circumference equally effective in tracking progress; greater weight loss if patient strongly
motivated; best time for weight-loss program when there is change in patient’s life, eg, entering college,
menopause; patient must be willing to take time to plan meals and to exercise
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| Secondary causes: check patient’s thyroid function; 0.4 mIU/L upper limit for normal thyroid-stimulating
hormone (TSH); hypothyroidism not primary factor in weight gain (≈6% of patients in speaker’s weight-loss
program have hypothyroidism), but normalizing thyroid function facilitates weight loss
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| Energy metabolism: studies show obese person burns more calories than lean person when walking; obese
person has more muscle mass; muscle burns more calories than fat; overweight or obesity result of consuming
too many calories; successful weight reduction dependent on reasonable food and exercise plans and behavior
changes; medication may be necessary
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| Counseling issues: identify source of concentrated carbohydrate and saturated fat in diet and substitute or
eliminate from food plan; initially easier for patient to find substitute for problem food than to change habit
contributing to weight gain; suggest patient change habit, ie, eating while watching television only after successful
weight loss; 2 yr of reinforcement of new behavior required before change permanent; problem behavior
can return if patient becomes chronically stressed, chronically ill, or feels losing weight not worth effort;
television—significant impediment to weight reduction; most accurate determinant of whether child will develop
diabetes or endothelial dysfunction; shown that children who eat while watching television have diet
containing ≈55% fat at that time
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| Nutritional counseling: www. mypramid.gov useful Web site for nutritional counseling; weight-reducing diets
containing 15% protein, <30% fat, and 55% carbohydrate recommended; patients more motivated to
change if able to choose own food plan than if one chosen for them; speaker suggests plan with <30% fat;
studies show most weight loss achieved with low-fat diet; low-fat, high-fiber diet and complex carbohydrate
and monounsaturated fat diet shown to decrease mortality and morbidity
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| Mediterranean diet: complex carbohydrate, monounsaturated fat diet; numerous alternative starches, eg,
bulgur, couscous, nuts (2 oz of pecans, walnuts, or almonds good snack); beneficial effect on lipid profile; reduces
inflammatory factors; ≈30% to 40% fat; low in saturated fat and high in monounsaturated fat; meat allowed
only few times per week and red meat few times per month; study showed 65% reduction in death from
cardiovascular (CV) events and cancer in people who followed Mediterranean diet, used alcohol moderately
(≤1 oz daily), walked 30 min 3 to 4 times weekly, and did not smoke; fiber—helps decrease appetite; controls
hunger; increases insulin sensitivity; decreases postmeal glucose; high-fiber bread recommended; Atkins-approved
bread contains insoluble fiber (reduces absorption of carbohydrates), creates sense of fullness
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| Atkins diet: ketotic; men able to follow longer than women; allows unlimited fat and protein; selective satiety
causes people to diminish food intake gradually; speaker does not discourage patient from following Atkins
diet, but recommends lower saturated fat options, eg, tuna rather than bacon; recommend patient include fruits
and vegetables early in diet; diet suppresses appetite with ketones (safe for short-term); 2-yr study of healthy
people following Atkins diet showed no problems; data show diet more effective in first 6 mo of use; at 1 year,
no statistically significant difference between conventional diet and low-carbohydrate diet; not recommended
if patient has evidence of microalbuminuria, renal insufficiency, or is pregnant; diet decreases low-density lipoprotein
(LDL), but long-term use not recommended if patient has coronary artery disease (CAD); low-carbohydrate,
nonketotic diet recommended for patient with CAD
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| Low-carbohydrate nonketotic diets: Sugar Busters, Zone, and Alleluia diet (no red, white, or blue foods,
high fiber); data show subjects randomized to protein diet did best compared to low-fat diet; protein increases
satiety
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| South Beach diet: reasonable diet; centers around foods with low glycemic index; some foods have more
readily available carbohydrates than others; awareness of glycemic index of foods important for patient with
metabolic syndrome; fiber decreases readily available carbohydrates; average American diet has high glycemic
index
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| Low-carbohydrate vs low-fat diet: low-carbohydrate diet improves lipid profile and lowers insulin level;
more muscle mass preserved with low-fat diet; exercise key to preserving muscle mass in patient on low-fat
diet; summary—caloric restriction key to weight loss, regardless of diet; low-carbohydrate diet with monounsaturated
fats decreases insulin resistance; diet high in complex carbohydrates and fiber also decreases insulin
resistance
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| Water and calcium: drinking 1.5 L of cold water burns 85 calories/day (includes diet soda); diet incorporating
low-fat dairy products shown to result in greater weight loss than isocaloric diet without low-fat dairy products,
but not significantly
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| Exercise: signals commitment to losing weight and maintaining weight loss; creates awareness of food; running
does not burn more calories than walking; exercise improves immunity and cognitive functioning; set
simple goals initially; recommend 30 min 3 times weekly, progressing to 1 hr daily
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| Behavioral changes: set achievable goals; food plan and exercise program should focus on improving self-esteem;
limiting alcohol intake recommended (alcohol can cause patient to lose control of food intake); recording
food intake beneficial in developing new food habits; recording food before eating decreases intake
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 | Phentermine: generic; central catecholamine stimulator; primary weight-loss medication; good tolerability;
patient must adhere to adequate food and fluid intake (1.5 L daily) to avoid dangerous side effects; potent
appetite suppressant; routinely monitor patient’s BP and glucose level; contraindicated in patients with history
of cardiac disease; patients often reluctant to mention side effects, especially if losing weight, so ask
specifically about side effects at each office visit
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| Sibutramine: poor patient acceptability because of ineffectiveness; approved for 1 yr of use; do not prescribe if patient
taking selective serotonin reuptake inhibitor (SSRI)
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| Orlistat (Xenical): decreases intra-abdominal fat; decreases triglycerides; helps to change conformation of
LDL; good for obese patient with dyslipidemia; costs $110 per month; Medicaid may reimburse cost if patient
has dyslipidemia; gastrointestinal (GI) events with overconsumption of fatty foods; decreases absorption
of fat-soluble vitamins; multivitamin at bedtime recommended; olestra also associated with adverse GI
events
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| Rimonabant: binds cannabinoid receptors; decreases desire for tobacco and chocolate; data show 8.7-kg
weight loss at 1 yr and 8.2-cm decrease in waist circumference; average of 16% increase in HDL with 1 yr
of use; product marketing to target lipid control; modest decrease in triglycerides with use
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| Recommendations for successful long-term weight management: recording daily food intake helpful;
most patients find low-calorie, low-fat diet effective; eating breakfast helps in controlling food intake at other
times of day; regular physical activity important; ≈25 miles of walking weekly needed in order to lose weight
and maintain loss
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| Bariatric surgery: improves diabetes and hypertension and decreases risk for metabolic syndrome; weight
lost as result of surgery regained, unless patient changes eating habits and engages in exercise program; patient
instructed to eat protein first (if still hungry, may eat carbohydrates) and stop eating when full; 80 oz of
fluids daily necessary to prevent ketosis; surgery alters enzymes in GI tract and may alter control of satiety
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Educational Objectives
| The goal of this program is to educate the listener about obesity management and weight loss programs. After
hearing and assimilating this program, the clinician will be better able to:
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| 1. Identify patients at risk for metabolic syndrome.
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| 2. Discuss the principles associated with successful weight reduction.
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| 3. Evaluate popular diets and their appropriateness for an individual patient.
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| 4. List medications that promote weight loss and discuss prescribing considerations associated with their
use.
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| 5. Describe principles associated with long-term weight maintenance.
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Discussed on This Program
Orlistat [Xenical]
Phentermine HCl [Adipex-P, Ionamin, Pro-Fast HS, Pro-Fast SA, Pro-Fast SR]
Rimonabant [Acomplia]
Sibutramine HCl [Meridia]
Suggested Reading
Folsom AR et al: Associations of general and abdominal obesity with multiple health outcomes in older
women: the Iowa Women’s Health Study. Arch Intern Med 160(14):2117, 2000; Foster GD et al: A randomized
trial of a low-carbohydrate diet for obesity. N Engl J Med 348(21):2082, 2003; Foster GD et al: Behavior treatment
of obesity. Am J Clin Nutr 82(1):230, 2005; Klem ML et al: A descriptive study of individuals successful at
long-term maintenance of substantial weight loss. Am J Clin Nutr 66(2):239, 1997; Knoops Kt et al: Mediterranean
diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project.
JAMA 292(12):1433, 2004; Lara-Castro C et al: Diet, insulin resistance, and obesity: zoning in on data for
Atkins dieters living in South Beach. J Clin Endocrinol Metab 89(9):4197, 2004; Meckling KA et al: Comparison
of a low-fat diet to a low-carbohydrate diet on weight loss, body composition, and risk factors for diabetes
and cardiovascular disease in free-living, overweight men and women. J Clin Endocrinol Metab 89(6):2717,
2004; Skov AR et al: Randomized trial on protein vs carbohydrate in ad libitum fat reduced diet for the treatment
of obesity. Int J Obes Relat Metab Disord 23(5):528, 1999; Yancy WS Jr et al: A low-carbohydrate, ketogenic
diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial. Ann Intern
Med 140(10):769, 2004; Yu-Poth S et al: Effects of the National Cholesterol Education Program’s Step I and
Step II dietary intervention programs on cardiovascular disease risk factors: a meta-analysis. Am J Clin Nutr
69(4):632, 1999.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant
financial relationship with the manufacturer or provider of any commercial product or service discussed.
The following has been disclosed: Dr. Piziak is a consultant with Bayer and Proctor & Gamble and is on the
Speakers’ Bureau of Proctor & Gamble, Sanofi Aventis, GlaxoSmithKline, Astra Zenica, Pfixer, and Novartis.
Dr. Piziak also has received research support from Roche, Sanofi Aventis, Eli Lilly, and Novartis.
Dr. Piziak was recorded at The Adult Patient: Male and Female Issues, sponsored by Scott & White, and held on June
20-24, 2005, in South Padre Island, Texas. The Audio-Digest Foundation thanks Dr. Piziak and Scott & White for
their cooperation in the production of this program.
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