obesity

CPhA

2006 Home Study Program

The Overweight and Obesity Epidemic Helping Patients Make Inormed Weight Loss Management Decisions Tom Smiley, BScPhm, PharmD

This program has been approved or 1.5 CEUs by the Canadian Council on Continuing Education in Pharmacy CCCEP #360-0106 This lesson is valid until February 10, 2009

EP Suggested retail price: $15 plus GST or CPhA members, $25 plus GST or non-members. This lesson is available rom the CPhA Online Learning Centre, with online marking at www.pharmacists.ca. I online access is not available to you, contact CPhA at 1-800- 917-9489.

cpha.learning.medi resource.com • All material ©2006 MediResource Inc.

Lesson description

Learning objectives

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t has become common knowledge that the prevalence of overweight and obesity are increasing at an epidemic rate, not only in North America, but around the world. Approximately 47% of the Canadian adult population is obese or overweight. The concern over the increasing prevalence of overweight and obesity is associated with the numerous health issues that arise as a result of excess body fat. Many patients are very self-conscious about their weight, and health professionals must be sensitive to that reality. Obesity should be treated as a complex, multifactorial disease that involves the integration of social, behavioural, cultural, physiological, metabolic, and genetic factors. This lesson will review health concerns for the population as a whole, and well as risks at the individual patient level. It will discuss strategies for the pharmacist to educate patients about the benets of achieving and maintaining a healthy weight as well as the risks and benets of diet programs and weight management aids.

fter completion of this continuing education lesson, pharmacists will be able to:

• discuss population health concerns associated with the increasing prevalence of overweight and obesity • educate patients about body mass index (BMI) and waist circumference with a focus on their associated individualized level of health risk • discuss the factors associated with obesity and overweight that play a major role in the pathogenesis of type 2 diabetes, coronary artery disease, and metabolic syndrome • educate obese and overweight patients about the benets of healthy weight to motivate them to consider losing weight • educate patients about the risks and benets as sociated with guideline-based and popular diet programs • educate patients about the risks and benets as sociated with prescription and non-prescriptionrequiring pharmacological weight management aids • discuss physical activity strategies as part of a comprehensive weight management program

Disclaimer

Wtimely, and educational Learning Series.

e have done our best to produce an accurate,

readers as professionals to interpret and apply this lesson’s information to their own practices. All rights reserved. For this lesson, in compliance with sections 10.2 and 10.3 of the Guidelines and Criteria for CCCEP Accreditation, the author, expert reviewers, and MediResource Inc. report no real or potential conict of interest with regard to this CE lesson.

However, MediResource Inc., the Canadian Pharmacists Association, the sponsors, the authors, the reviewers, and the editors assume no responsibility for any errors or consequences arising from the use of information contained within this program. With the constant changes in practice and regional differences, it remains the responsibility of the

The Overweight and Obesity Epidemic cpha.learning.medi resource.com • All material ©2006 MediResource Inc.

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Author Tom Smiley, BScPhm, PharmD Tom Smiley is a pharmacist consultant with Pharmavision Health Consulting Inc. in Brantford, Ontario. In addition to his clinical experience with patients over the past 25 years, Tom has developed many CE lessons and workshops for pharma cists including management of obesity, nutrition, cardiovascular disease, metabolic syndrome, and diabetes. Tom’s review papers on the topics of metabolic syndrome and progression of type 2

diabetes have been published in the Canadian Journal of Cardiology and the Canadian Journal of Diabetes. Tom currently represents District 12 of the Ontario Pharmacists Association Board of Directors and also serves on the executive committee. Tom practices part-time at Dell Pharmacy in Brantford and is a member of the Family Health Team Action Group appointed by the Ontario Ministry of Health.

Expert reviewers P. Joan Bobyn, BSP, PhD While holding an administrative position at the University of Saskatchewan (U. of S.), Joan also

Zubin Austin, BScPhm, MBA, MIS, PhD Zubin Austin is Assistant Professor at the Leslie Dan Faculty of Pharmacy, University of Toronto, and a clinical pharmacist at Mount Sinai Hospital. He has extensive experience in pharmacy education, research, and practice, and has published over 30 peer reviewed papers. He currently coordinates senior-level pharmacy practice courses, as well as introductory courses in Applied Pharmaceutical Sciences. He currently teaches a senior-level course

fulllls three part-time contracts related to her educational background: 1) Coordinator of the Saskatchewan College of Pharmacists’ Learning Portfolio Audit Project; 2) Research Ofcer, Cholesterol Optimization Program for High-Risk Patients in Primary Health Care, with Saskatchewan Health; and 3) Program Coordinator, InterProfessional Continuing Education CPD Project (a subcommittee of the U. of S. Health Science Deans’ Committee). To date, Joan has acted as an expert reviewer for four pharmacy nutrition-related professional development modules and has written two modules. At the U. of S., Joan also serves as a professional afliate to the division of Dietetics, College of Phar macy and Nutrition; on the advisory committee for a Nutrition M.Sc. student; and as co-investigator on a dietary study of Canadians. Joan participated on the planning committee for a CME obesity confer ence held in Saskatoon in 2003.

in behaviour modication and management. He is currently a co-investigator on a research project funded by the Canadian Diabetes Association examining strategies to encourage weight management, particularly amongst those at risk for diabetes.


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Contents page 1 1 1 1 2 1 2 2 2 3 3 3 4 4 4 5 6 6 6 7 7 7 7 8 8 9 9 10 11 13

1. Introduction 2. Classifcation o overweight and obesity 2.1 The body mass index (BMI) 2.2 The impact o waist circumerence 3. Abdominal obesity and health risks Table1.LevelohealthrisksassociatedwithBMIcategories 3.1 Abdominal obesity and defnition o the metabolic syndrome 3.2 Contributions o abdominal at to pathogenesis o the metabolic syndrome Figure1.Relationshipbetweenabdominalobesityandrisk actorsorcoronaryarterydiseaseanddiabetes Table2.NorthAmericandefnitionothemetabolicsyndrome Table3.InternationalDiabetesFederationproposed defnitionometabolicsyndrome 4. Identiying the problem: Where have we gone wrong? 4.1 Some good news! The health benefts associated with losing weight 5. Weight loss: What the guidelines say Table4.Recommendeddailyenergyintake(Calories/day) 5.1 Behaviour modifcation 6. Alternative weight loss strategies: Good marketing or good science? 6.1 Low-carbohydrate diets 6.2 Moderate-at diets 6.3 Low-at and very-low-at diets 6.4 Very-low-calorie diets 6.5 Weight loss programs: The bottom line (“fgure”-atively and fnancially) 7. Pharmacological options or weight management 7.1 Orlistat 7.2 Sibutramine 7.3 Over-the-counter weight loss preparations 8. Physical activity and contribution to weight loss programs 9. Pharmacists and weight management: drugs not required Reerences Questions


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1. Introduction

2. Classifcation o overweight and obesity

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t has become common knowledge that the prevalence of overweight and obesity are increasing at an epidemic rate, not only in North America but around the world. Approximately 47% of the Canadian adult population are obese or overweight (2.8 million Canadians and 6 million Canadians, respectively). The number of obese adults in Canada almost tripled between the years 1985 and 2001.1 The prevalence of childhood obesity in Canada is just as alarming. Excess weight among boys has increased from 15% of the population in 1981 to 28.8% in 1996. In girls, the gures during the same time period increased from 15% to 23.6%. 2 Overall, the rate of obesity has more than doubled, from 5% to 13.5% for boys and 11.8% for girls. The concern over increasing prevalence of overweight and obesity is associated with the numerous health issues that arise as a result of excess body fat. The direct medical costs attributable to obesity were estimated at 1.8 billion dollars in 1997 (2.4% of all medical costs in Canada). 3 In 2003, the Heart and Stroke Foundation of Canada declared that “the increasing number of overweight and obese Canadians now poses one of the greatest threats ever to public health in this country.” 1 Many patients are very self-conscious about their weight, and health professionals must be sensitive to that reality. Obesity should be treated as a complex, multifactorial disease that involves the integration of social, behavioural, cultural, physiological, metabolic, and genetic factors. 4 Weight loss management programs require patience and motivation. In educating patients on the importance of healthy weight and weight loss strategies, we must be nonjudgmental and individualize recommendations, remembering that weight loss is a “journey, not a destination.” 4

The Canadian Guidelines for Body Weight Classication in Adults is aligned with the recommendations of the World Health Organization (WHO). It is important to understand that this classication system is not intended for use in: • people less than 18 years old • pregnant or lactating women • highly muscular adults Special consideration should be given when using the system for individuals with very lean body build, adults over 65 years, and certain ethnic and racial groups.

2.1 The body mass index (BMI) BMI is dened as weight (kg)/ height (m²). It is not a direct measure of body fat but does factor in the effects of height on body weight. It is the most widely used indicator of health risk associated with weight. 5 Table 1 outlines weight categories according to BMI and associated level of health risks. It is not a comfortable task to let a client know that their weight is posing a signicant risk to their health. A tactful approach might include a review of the patient’s current overall health risks and how they are related to lifestyle habits, including diet and exercise. Easy-to-read literature outlining health risks associated with overweight and obesity will back up efforts to raise awareness of this extremely important but potentially delicate issue. An excellent overview of health risks associated with BMI, as well as a BMI chart, can be found on the Health Canada website (“Canadian Guidelines for Body Weight Classication in Adults”) at www. hc-sc.gc.ca/fn-an/nutrition/weights-poids/guideld-adult/cg_quick_ref-ldc_rapide_ref_e.html.5

Table 1. Level o health risks associated with BMI categories

Classifcation

Risk o BMI category developing (kg/m²) health problems

Underweight

<18.5

Increased

Normal weight

18.5–24.9

Least

Overweight

25.0–29.9

Increased

Class I

30.0–34.9

High

Class II

35.0–39.9

Very high

Class III

≥40.0

Extremely high

2.2 The impact o waist circumerence Abdominal fat (visceral adiposity) is associated with much greater health risk than fat that is found around the hips (for example). This speaks to the common analogy of the “apple shape” (excess fat around the waist) versus the “pear shape” (excess weight around the hips). Excess abdominal fat increases the risk of having cardiovascular disease risk factors associated with the metabolic syndrome (e.g., hypertension, dyslipidemia – see section 3.1). According to the Canadian Guidelines for Body Weight Classication in Adults, men with a waist circumference of 102 cm (40 inches) or greater and women with a waist circumference of 88 cm (35 inches) or greater have an increased risk of developing health problems such as type 2 dia-

Obese:


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betes, coronary artery disease, and hypertension. 5 A study published in November 2005 by Yusuf et al. supports the argument that waist-to-hip ratio (WHR) and waist circumference are much better indicators of cardiovascular risk than BMI. 6 Through a case-controlled study, the investigators assessed the risk of acute myocardial infarction (MI) among 27,098 participants representing several major ethnic groups in 52 countries. They found that the population-attributable risks of MI for increased WHR in the top two population quintiles was 24.3%, compared with 7.7% for the top two quintiles of BMI. The authors concluded that redenition of obesity based on WHR instead of BMI would increase the estimate of MI attributable to obesity in most ethnic groups. 6 Health Canada suggests that a WHR of 0.8 or less in women and 1.0 or less in men is associated with lower health risk (see www.hc-sc.gc.ca/fn-an/nutrition/ weights-poids/vitalit/apple_pear-pomme_poire_ e.html for patient information).

Figure 1. Relationship between abdominal obesity and risk actors or coronary artery disease and diabetes9 Abdominal obesity

↑ ree atty acids

↑ insulin resistance

↑ blood glucose ↑ triglycerides ↓ HDL

3. Abdominal obesity and health risks

↑ blood pressure

Type 2 diabetes

Coronary artery disease

Health risks associated with overweight and obesity include dyslipidemia, hypertension, coronary artery disease, and type 2 diabetes, as well as gallbladder disease, obstructive sleep apnea, and certain types of cancer (breast, colon, endometrial, kidney and esophageal cancers). 7

• As noted in Figure 1, visceral fat is associated with increased free fatty acid (FFA) levels which result from enhanced lipolytic activity of the abundant triglycerides. The accumulation of FFAs in the liver leads to excess very low density lipoprotein (VLDL) production and increases gluconeogenesis, while reducing insulin sensitivity. • Insulin resistance decreases the activity of the lipoprotein lipase enzyme that is responsible for transforming triglyceride rich chylomicrons to HDL and VLDL to LDL. This leads to slower VLDL clearance, reduced HDL production, and an increase in smaller and denser LDL (which are more easily oxidized and penetrate arterial walls more easily). • Insulin resistance related to obesity reduces afnity for the LDL receptor, and therefore may interfere with clearance of LDL particles. • Visceral fat produces and secretes inammatory cytokines including tumor necrosis factor-alpha and interleukin 6. These peptides inhibit insulin receptor signalling and block insulin action. • The metabolic syndrome is associated with a hypercoagulable state as a result of secretion of type 1 plasminogen activator inhibitor (preventing plasminogen conversion to plasmin).

3.1 Abdominal obesity and defnition o the metabolic syndrome Visceral fat or adiposity, which is found around the belly, is the principle parameter associated with the metabolic syndrome. The associated pathophysiology is very interesting, and new research is still evolving with respect to the exact mechanisms and consequences of the metabolic syndrome state. The metabolic syndrome (previously known as syndrome X and insulin resistance syndrome) is now regarded as an important precursor of coronary artery disease and type 2 diabetes (see Figure 1). It has been dened by the Canadian Diabetes Association as “a multifaceted condition characterized by a distinctive constellation of abnormalities that include abdominal obesity, hypertension, dyslipidemia, insulin resistance and dysglycemia.” 8 Figure 1 outlines the relationship between abdominal obesity and risk factors associated with coronary artery disease and type 2 diabetes. 9

3.2 Contributions o abdominal at to pathogenesis o the metabolic syndrome Following is a brief synopsis of the many processes at work in abdominal fat that promote a state of metabolic syndrome9:

Increased insulin resistance promotes impaired fasting glucose, elevated blood pressure, and dyslipidemia.


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clinically and epidemiologically useful denition of metabolic syndrome. 11 It was agreed that central obesity should be a requirement (not an option) for metabolic syndrome diagnosis. It was also agreed, however, that waist circumference as a measure of central adiposity should be ethnic-specic, with different cutpoints included in the denition.11 Table 3 is the consensus-derived denition that may be accepted globally in the near future. If so, research in the area of metabolic syndrome will be much more homogeneous in nature, with studies being more easily compared as a result of the common denition. In a study of approximately 8,000 patients participating in the National Health and Nutrition Examination Survey (NHANES III), the risk for type 2 diabetes was seen to increase in a progressive fashion in men and women as BMI rose above 25 kg/m².15,16 Men and women with a BMI of 35 or greater have a 42 and 93 times the risk, respectively, of developing diabetes compared to those with a BMI of 23 kg/m² or less. 15,16 Weight counselling related to excess BMI or waist circumference can present a unique opportunity for pharmacists. Patients could be offered a simple checklist to allow for risk assessment based on a calculation of BMI and waist measurement. In addition, those who have been identied with abdominal obesity or one of the risk factors associated with metabolic syndrome (i.e., elevated blood pressure, dyslipidemia, or elevated fasting plasma glucose) should be especially urged to remain faithful to yearly risk factor checks.

Table 2. North American defnition o the metabolic syndrome Three or more o the ollowing risk actors: • Abdominal obesity – large waist circumerence › >102 cm (men) › >88 cm (women) • Blood pressure ≥130/85 mmHg • HDL-C (High-density lipoprotein) › <1.0 mmol/L (men) › <1.3 mmol/L (women) • Triglycerides ≥1.7 mmol/L • Fasting plasma glucose ≥6.1 mmol/L

Table 3. International Diabetes Federation proposed defnition o metabolic syndrome11 Central obesity (defned as waist circumerence exceeding values defned according to ethnicity),* plus any two o the ollowing our actors: • HDL › <1.03 mmol/L (men) › <1.29 mmol/L (women) • Triglycerides ≥1.7 mmol/L • Blood pressure ≥130/85 mm Hg or treatment o previously diagnosed hypertension • Fasting plasma glucose ≥5.6 mmol/L or previously diagnosed type 2 diabetes

*Waist circumerence according to country/ethnic group: Men Women North Americans Europids, Sub-Saharan Aricans, Eastern Mediterranean and Middle East (Arab) populations

≥102 cm ≥88 cm

4. Identiying the problem: Where have we gone wrong?

≥94 cm ≥80 cm

South Asians, Chinese, Ethnic South and Central Americans

≥90 cm ≥80 cm

Japanese

≥85 cm ≥90 cm

Increased food intake attributable at least in part to increase in portion sizes, combined with a reduction in physical activity, is largely responsible for the North American obesity epidemic.17 From 1991 to 2002, energy intake from food by Canadians increased by 18%, while fat intake increased on average by 22%.1 During that same time period, the average calorie consumption increased to 2788 calories daily from 2356 calories. This exceeds the recommended daily energy intake for almost every age group, according to Dietitians of Canada recommendations (see Table 4) 1. As we grow older, our resting metabolic rate declines. In other words, we do not burn off as many calories when we are not active. This is reected in Table 4, as recommended daily energy intake declines with age. Unfortunately, many Canadians continue to eat the same portions, if not more, as they age. Education about this principle

Table 2 outlines the North American denition of metabolic syndrome (originally derived by the National Cholesterol Education Program Adult Treatment Panel III and as published in the 2003 Canadian Diabetes Association Clinical Practice Guidelines and the Canadian Dyslipidemia Guidelines).8,10 Around the globe there are currently three different denitions of the metabolic syndrome being used (the WHO denition and that of the European Study Group for Insulin Resistance are the other two). In 2004 the International Diabetes Federation held a consensus meeting of global experts in an attempt to reach agreement on a single common


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levels (average BMI 34.0) were randomly assigned to lifestyle intervention consisting of targets of 7% weight loss and at least 150 minutes of physiAge (years): 13–15 16–18 19–24 25–49 50–74 75+ cal activity weekly, or metformin 850 Male 2800 3200 3000 2700 2300 2000 mg bid, or placebo. 21 After an average Female 2200 2100 2100 1900 1800 1700 of 2.8 years, there was a risk reduction for diabetes of 58% in the lifestyle can be part of an overall health professional stratgroup and 31% in the metformin group, comegy to raise awareness of the causes of overweight pared to placebo. 21 and obesity. • In the Finnish Diabetes Prevention Study, 522 A large part of the overall escalating problem of overweight men and women with impaired overweight and obesity lies in our view of portion glucose tolerance (mean BMI of 31) were ransizes. In 1957, a typical soft drink accompanying domly assigned to target 5% weight reduction a meal at a restaurant would be approximately 6 and moderate exercise for at least 30 minutes ounces. Today, we might get a 64-ounce soft drink daily or a control group (carry on with previous if we ask to “super-size it.” Similarly, a well known lifestyle).22 Similar to the Diabetes Prevention fast-food outlet has decided to serve “triple-thick” Program, there was a 58% risk reduction in the shakes. The problem is that these beverages cononset of diabetes after four years. tain 1160 calories (the equivalent of approximately three one-quarter-pound hamburgers) and the total Weight loss also benets those who have daily calorie allowance recommended for many already been diagnosed with type 2 diabetes. A 18 women wishing to diet (see Section 3.0). These are critical message for patients with diabetes is that just two examples of unhealthy changes in the fast- even loss of 5% of body weight can improve insulin food world to which we have become accustomed. action, reduce fasting blood glucose concentrations, Raising awareness about portion sizes is just one and reduce the need for diabetes medications. 23 way in which pharmacists can contribute to the Helping patients understand the risks associated with overweight and obesity as well as the ght against obesity. Approximately 62% of Canadians are not active advantages of losing weight may lay the foundaenough to gain health benets from a physically tion for a person choosing a healthier lifestyle. 19 active lifestyle. Outdoor activities have become Assuring overweight or obese patients that you less accessible to children than in the past, in part will be available for discussion of weight managedue to transportation and cost barriers. 17 ment will also be viewed as an important support system should they decide to engage in healthier 4.1 Some good news! The health benefts lifestyle activities.

Table 4. Recommended daily energy intake (Calories/day)1

associated with losing weight

We need to help patients understand the benets of weight loss as part of an overall health strategy. Following are some of the health advantages gained by a 10 kg weight loss 20: • • • • • •

5. Weight loss: What the guidelines say Weight is gained when more calories are ingested than are expended in energy. A simple way to explain expectations for weight loss is the following:

30–40% reduction in diabetes-related deaths 20–25% decrease in total mortality reduction of 10/20 mmHg blood pressure reduction of LDL cholesterol by 15% reduction of 10% total cholesterol reduction of 30–50% in fasting blood glucose

• One-half kilogram (one pound) of fat contains approximately 3500 calories. To take this much weight off in one week requires that 500 more calories per day be expended than ingested (i.e., a 500-calorie-per-day decit). Therefore, a calorie decit of 500 to 1000 calories per day will result in loss of 0.5 kg to 1 kg (1–2 pounds) per week.

As discussed previously, obese patients are at increased risk for type 2 diabetes. Studies have shown, however, that a lifestyle program that includes weight loss and an exercise program signicantly reduces this risk.

Comprehensive guidelines published The National Heart, Lung and Blood Institute North American Association for the Study of Obesity and available online at www.nhlbi.nih.gov/guidelines/ obesity/practgde.htm recommend that patients set

• In the Diabetes Prevention Program, over 3000 patients without diabetes but with elevated fasting plasma glucose and post-prandial glucose


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daily, with an upper limit of 35 grams. 4 Fibre intake has also been proposed to aid weight loss by reducing absorption of macronutrients and altering secretion of gut hormones. 25

an initial target of 10% weight loss over a 6-month period.4 This corresponds nicely to the 0.5–1 kg per week loss outlined above. Research has found that greater rates of weight loss do not achieve better long-term results.4 After the weight has been taken off, it is important that weight maintenance be achieved through continued diet, physical activity, and behaviour modications. Further weight loss should only be considered after a period of weight maintenance, since studies have shown that it is difcult to continue to lose weight after a 6-month period.4 Following are some guidelines for sensible weight-loss diets:

5.1 Behaviour modifcation The ideal diet is one that the patient can maintain with lifestyle changes that are individualized. Behaviour therapy helps the patient to overcome barriers to adherence with dietary therapy and/or increased physical activity. 4 In this regard, it is very important to assess the patient’s readiness to implement a plan for weight reduction. The following approach may help you to help your patients who wish to discuss weight loss strategy: 4

• Generally, diets containing 1000 to 1200 calories daily should be chosen by most women, and 1200–1600 calories per day for most men. 4 • Canada’s Food Guide is an excellent nutritional resource. It recommends servings from each of the following four food groups: › 5–12 servings of grain products per day (emphasize whole grain) › 5–10 servings of vegetables and fruit per day › 2–4 servings of low-fat milk products per day › 2–3 servings of low-fat meat and alternatives per day • The diet should include no more than 30% energy as fat and no more than 10% as saturated fat. The diet should provide 55% of energy as carbohydrates from a variety of sources. • When following these recommendations, the participant would be ingesting a range of 1800–3200 calories daily. Therefore, people wanting to lose weight should choose from the lower range of servings (or a bit less in some cases) and/or increase physical activity appro priately. Canada’s Food Guide is available online at www.hc-sc.gc.ca/hpfb-dgpsa/onppbppn/food_guide_rainbow_e.html.24 Please note that Canada’s Food Guide is currently being updated. The new version is expected to be released in Spring 2006 and promises to improve ease of serving size calculations. • Fat-modied foods may provide a helpful strat egy for lowering total fat intake but will only be effective if they are also low in calories and if there is no compensation by calories from other foods.4 • Complex carbohydrates from different vegetables, fruits, and whole grains are good sources of vitamins, minerals, and bre. Fibre intake is inversely associated with body weight and body fat.25 A diet rich in all types of bre may aid in weight management by promoting satiety at lower levels of calorie and fat intake. Some experts recommend 20–30 grams of bre

• As obesity is a frustrating, troubling, and visible problem, patients may have many issues to deal with. They may be defensive about the problem. Therefore, it is imperative to communicate a nonjudgmental attitude that distinguishes between the weight problem and the patient with the problem. Ask the patient how their weight history has affected their life and express concern about the health risks associated with the condition. • It is the patient who must make the changes to achieve weight loss, so they should be an active partner in goal setting and how to achieve the weight loss. Help the patient to understand the importance of setting achievable, individualized goals. Strategies should be selected on the basis of their likely impact on weight and health, the patient’s current status, and the patient’s willingness and ability to implement them. • Educate patients through the use of openended questions. For example, “One thing that seems to be very important for most patients is physical activity. What are your thoughts about increasing your activity level?” • Help patients to understand the social or environmental cues that lead to undesired eating. For example, some might like to overeat while watching television. Implementing a strategy to overcome the undesired effects of this activity might include asking the patient if they believe they could watch television without eating, or replacing unhealthy food such as potato chips with healthier foods that are also associated with less caloric intake, such as a piece of fruit. Educating patients to eat more slowly will allow the signals of satiety to take place more quickly. These are just a few examples of partnering and educating patients about weight management alternatives while allowing them to be in control of their overall plan.


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6. Alternative weight loss strategies: Good marketing or good science?

of water, the body loses water as glycogen is utilized. Fat loss doesn’t begin until glycogen stores are used up and the body turns to fat as its energy source. This is the point at which ketones can be measured in the urine. 27 The Atkins Diet: Studies cited by Atkins to promote his diet were of limited duration, conducted on a small number of people, lacked adequate controls, and used ill-dened diets. 27 Recently, however, two studies, one of 6 months duration and the other 12 months, published in the New England Journal of Medicine were viewed as a victory for proponents of the Atkins Diet. 28,29 Both studies showed a faster rate of weight loss among those randomized to the Atkins Diet compared with higher-carbohydrate-based diets for the rst 2–6 months. In the 12-month study, however, the Atkins Diet group gained weight back faster than the higher-carbohydrate group. The eventual weight differences were not signicant at the end of one year.29 Ultimately, many researchers agree that it is solely the reduction in calorie intake (beyond the initial water loss in low-carbohydrate diets) that is responsible for the weight loss resulting from any diet, including the low-carbohydrate variety. Improved metabolic proles are due to the weight loss that occurs in any diet program. The South Beach Diet: This diet was made popular by Dr. Arthur Agatston, who claims he created it after becoming disillusioned with moderate-fat diets (i.e., “guideline” based or Weight Watchers) and the Atkins Diet. 30 The South Beach diet lies somewhere in between, as it is divided into three phases:

Mass media includes a plethora of advertising for various weight management programs. One wonders how all of the companies engaged in this business could remain viable. Perhaps the answer is in “repeat business.” This speaks to the difculty in maintaining weight loss with virtually every weight loss program available. A recent systematic review of major commercial weight loss programs found that with the exception of one trial of Weight Watchers, the evidence to support the use of major commercial and self-help weight loss programs is “sub-optimal.”26 This section will help pharmacists discuss the overall approach, merits, and shortcomings of popular diet strategies. Diets can be generally categorized as 27: • low-carbohydrate (<100 g carbohydrate per day), high-fat (55–65% of calories), high-protein (25–30% of calories) diets (e.g., Atkins Diet, South Beach Diet, Protein Power) • moderate-fat (20–30% of calories), balanced nutrient-reduction diets, high in carbohydrate (55–60 % of calories) and moderate in protein (15–20% of calories) (e.g., Weight Watchers, Jenny Craig, Nutri-Systems, Dietary Approaches to Stop Hypertension [DASH] diet) • low-fat (11–19%) diets and very-low-fat (<10%), very high carbohydrate, moderate-protein diets (e.g., Dr. Dean Ornish’s Program for Reversing Heart Disease, The New Pritkin Program) • very-low-calorie diets (e.g., Bernstein diet) The “guideline” approach to weight loss is of the moderate-fat variety, as it most closely approximates nutritional balance as recommended by Canada’s Food Guide.

• Phase 1 lasts 14 days and is truly a low-carbohydrate diet. • Phase 2 allows high-bre carbohydrates such as whole-grain breads and is maintained until the weight loss goal is reached. • Phase 3 is the weight maintenance phase and is more liberal with respect to carbohydrates.

6.1 Low-carbohydrate diets The low-carbohydrate diets have been very popular over recent years. Proponents of the diet claim that people who overeat do so most often as a result of addictive craving for carbohydrates. 27 They also propose that overproduction of insulin that is driven by high carbohydrate intake is the cause of metabolic imbalances that result in obesity.27 Low-carbohydrate diets seem to help people take weight off very quickly, which is very attractive to the person trying to shed pounds. It is interesting to note, however, that the initial weight loss achieved through low-carbohydrate diets results from excess water loss, which occurs when the body initially turns to glycogen breakdown (yielding glucose) for its energy source. 27 Because every gram of glycogen is stored with three grams

Additional low-carbohydrate diets and comments:

• The Zone Diet: Promotes 40% carbohydrates, 30% fat, 30% protein – difcult to maintain with strict diet protocol. • Protein Power: Amount of protein needed in diet is estimated by activity. Not scientically based, and causes ketosis due to low carbohydrate intake.

6.2 Moderate-at diets These diets follow the basic principles of “guideline” recommendations. 27 Meal replacement plans


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also fall into this category and have the advantage of structure with respect to knowing exactly how many calories and nutrients are in each serving. The prime discussion within approaches to these diets is whether a low-energy (i.e., low calorie) or low-fat diet ad libitum (i.e., reduced fat but calories not watched) is best. Scientic analysis to date concludes that weight and body fat loss occurs with both, but one is not necessarily better than the other.27

restricted menu plans providing the same energy intake and assessed potential effects of their longterm use with weight-maintaining energy intakes. 32 Diets used for evaluation were the Atkins Diet, Protein Power, Sugar Busters, the Zone, Pritikin, Ornish Diet, and “guideline” based approaches such as Dr. Anderson’s High-Fiber Fitness Plan. The Atkins and Protein Power diets were very high in total and saturated fat compared to current dietary guidelines. It was concluded that long-term use of these diets could signicantly increase serum cholesterol concentrations and risk for coronary artery disease. The Sugar Busters and Zone diets would lower serum cholesterol concentrations and likely reduce risk for coronary artery disease. Higher-carbohydrate, higher-bre, lowerfat diets would have the most benecial effect with respect to decreasing serum cholesterol concentrations.32 Patients who partake in diets that restrict carbohydrates risk reduction of nutrient intake associated with the fortication of certain foods. In a study that compared low-carbohydrate to highcarbohydrate diets, nutrient density of vitamin A, carotene, vitamin C, folate, calcium, magnesium, and iron increased with percent total energy derived from carbohydrate. 33 Women of childbearing age, for example, may inadvertently reduce their intake of folic acid while using low-carbohydrate diets. This, in turn, could increase risk for folate-deciency-linked birth defects should they become pregnant. In summary, weight loss occurs as a result of reduction in calories (regardless of source) combined with increased physical activity. The key to a successful weight loss program is one that can be maintained while providing balanced and adequate nutrition. Although a “guideline” based diet recommended by a dietitian may not be as popular with many because patience is required, it is the approach which makes most sense for economical, long-term weight control.

6.3 Low-at and very-low-at diets These diets promote a diet consisting of less than 10% (very-low-fat) and up to 19% of daily calories as fat.27 They tend to be high in carbohydrate and low in protein. These diets have not been as popular as the low-carbohydrate diets, and there is little scientic information on their effect on body weight and body composition. The main programs incorporating this type of diet are Dr. Dean Ornish’s Program for Reversing Heart Disease and the Pritikin Program.27 These programs also promote changes in exercise and lifestyle, including stress reduction and emotional support. Evidence from very-low-fat diet programs suggests they are low in vitamins E and B 12 and zinc. Analysis of these programs suggests that weight loss derived from very-low-fat diets may be the result of lifestyle modication, which may include decreased fat and energy intake, increased energy expenditure, or both. 27

6.4 Very-low-calorie diets The Bernstein Diet is an example of a diet that provides very few calories on a daily basis. In fact, the diet supplies about 850–950 calories daily. Patients are monitored for compliance with the diet by having them come in for vitamin B 6 and B12 injections three times weekly. Weight loss occurs at a rate of about 2 kg weekly, but weight goes back on just as quickly when the diet is abandoned. 27 When interviewed by CBC’s Marketplace, Dr. George Blackburn, an internationally recognized expert in obesity and clinical nutrition from Harvard University, commented that diets offering less than 1000 calories a day put a person into a “semistarvation” mode.31 Risk for nausea and lightheadedness is increased, as is risk for gall bladder attack. Dr. Blackburn concluded his comments by saying “Rapid weight loss is not worthwhile except in a medical emergency.” 31

7. Pharmacological options or weight management Eligibility for the use of pharmacological treatment is the same for all agents approved in Canada: • For use in obese patients who have not responded to an appropriate weight-reducing diet alone with a BMI ³30 kg/m² or a BMI ³27 kg/m² in the presence of other risk factors (e.g., hypertension, type 2 diabetes, dyslipidemia, excess visceral fat).

6.5 Weight loss programs: The bottom line (“fgure”-atively and fnancially) In an interesting computer-assisted analysis of weight loss strategies, Anderson et al. calculated the nutrient content of all diets using energy-


7

Orlistat and sibutramine are currently the only two medications approved in Canada for long-term weight control. Sympathomimetic agents such as phentermine, diethylpropion, and mazindol may work in the short term, but tolerance to the effects of these agents usually develops. Therefore, all of these drugs are indicated for only “a few weeks” according to their product monographs. 34–36 The most common adverse effects with these agents are dry mouth, nervousness, constipation, and hypertension.37 They are contraindicated in patients with moderate-to-severe hypertension and in those with cardiovascular disease. Caution should be observed in people with anxiety disorders and other conditions that may be agitated as a result of the stimulant effect. These agents are related to amphetamines and therefore may be physically and psychologically addictive. 37

in nature. Increased fat excretion may cause abdominal pain, oily spotting, fecal urgency, atulence with discharge, fatty stools, fecal incontinence, and increased defecation. There is a much higher risk of experiencing these side effects if more than 30% of daily calories is obtained from fat, or any single meal has very high fat content. In a recent meta-analysis of trials it was found that orlistat increased risk of diarrhea by 3.4 times compared to placebo. 41 Flatulence was increased 3.4 times, while bloating, abdominal pain, and dyspepsia were increased 1.48 times compared to placebo. 41 • Orlisat is contraindicated in patients with chronic malabsorption syndrome and in patients with cholestasis.42 • Absorption of lipid-soluble vitamins (A,D,E,K) and beta-carotene may be reduced with orlistat therapy. Patients should be advised to take a multivitamin containing these particular vitamins on a daily basis, at a time that does not coincide with orlistat dosing. 42

7.1 Orlistat Orlistat inhibits gastric, carboxyl ester, lipoprotein, and pancreatic lipase. It blocks the hydrolysis of dietary fats in the form of triglycerides, causing dietary fats to remain in the intestine and be excreted in the stools. 37 Orlistat inhibits dietary fat absorption by about 30%. Weight loss is attributed to the resultant reduced caloric intake. Very little of the drug is absorbed systemically. 37

7.2 Sibutramine • Sibutramine was initially researched for its potential in treatment of depression. It inhibits the reuptake of norepinephrine, serotonin, and dopamine in the central nervous system. This drug was found to promote a feeling of satiety (fullness), which contributes to reduced caloric intake, and caused increased energy expenditure through induction of thermogenesis. This mechanism of action differs from that of sympathetic agents such as phentermine and diethylpropion, which are anorexiants and cause both serotonin and norepinephrine release. Sibutramine use has not been associated with adverse effects such as pulmonary hypertension and cardiac valve disease that have been linked to the use of centrally-acting anorexic agents such as fenuramine.37 • A recent meta-analysis included 5 studies that reported 12-month outcomes for sibutraminetreated patients.41 An average of 4.5 kg more weight was lost with sibutramine compared to placebo in these patients. Adults with known cardiovascular disease were generally excluded from most primary studies. • Fasting blood glucose and HbA1c level decreased slightly in sibutramine-treated patients in the meta-analysis. Consistent effects on lipids were not observed. Heart rate was consistently increased by about 4 beats per minute. 44 • Sibutramine is a cytochrome P450 3A4 substrate. Patients taking P450 3A4 inhibitors such as erythromycin or ketoconazole should be monitored closely for blood pressure and/or heart

• A recent meta-analysis included 22 studies of orlistat with 12-month outcomes. 41 A mean weight loss for oristat-treated patients of 2.89 kg was reported for these patients. 41 The average BMI of patients included in these studies was 36.7 kg/m². • Orlistat is the only weight management drug with an additional indication for use in combination with antidiabetic agents (sulfonylureas, metformin, insulin). It is indicated to improve blood glucose control in overweight or obese type 2 diabetes patients who are inadequately controlled on diet, exercise, and one or more of a sulfonylurea, metformin, or insulin. 42 • Orlistat has been shown to reduce risk for diabetes in obese individuals. The XENical in the pre vention of Diabetes in Obese Subjects (XENDOS) study randomized over 3,000 patients with a BMI ³30 kg/m² to lifestyle changes plus either orlistat 120 mg or placebo three times daily. 43 After four years, mean weight loss was signicantly greater in the orlistat group (5.8 kg vs. 3.0 kg). Cumulative incidence of diabetes was 9.0% with placebo and 6.2% with orlistat (an absolute risk reduction of 2.8%). This difference was signicant, repre senting a risk reduction of 37.3%. 43 • The most frequent adverse effects associated with orlistat therapy are gastrointestinal


8

rate changes. Sibutramine and monamine oxidase inhibitors, as well as SSRIs, St. John’s wort, or other centrally-acting drugs used for the treatment of psychiatric disorders must not be used together.44 For MAOIs and other centrallyacting drugs, at least 14 days should should elapse after discontinuation of the drug before sibutramine therapy is started. 44 • The sibutramine product monograph recommends regular monitoring of blood pressure and heart rate in the rst three months of treat ment, at intervals of at least every two weeks. Thereafter, regular blood pressure checks should be conducted at one-to-three-month intervals. Treatment should be discontinued in patients who have an increase at two consecutive visits of 10 mmHg or greater in systolic or diastolic blood pressure, or increase in resting heart rate of 10 beats per minute or greater. In previously well-controlled hypertensive patients, treatment should be discontinued if blood pressure exceeds 145/90 mmHg at two consecutive readings. 44 • Sibutramine is contraindicated in patients with a history of coronary artery disease, congestive heart failure, arrhythmias, or cerebrovascular disease (stroke or transient ischemic attack). It is also contraindicated in patients with a history of, or presence of, major eating disorder such as anorexia nervosa or bulimia nervosa. 44

•

•

•

7.3 Over-the-counter weight loss preparations

•

Non-prescription over-the-counter weight loss products are marketed well and are more widely used than prescription medications.45 It is therefore important for pharmacists to inquire about OTC preparations that patients may be currently using when discussing weight loss strategies with them. Laxatives: Many patients are under the incorrect impression that laxatives help one to lose weight. In fact, the absorption of calories has already occurred by the time the laxative takes effect. Patients should be advised against using laxatives for this purpose and cautioned about the potential for electrolyte imbalance and constipation resulting from the suppression of the natural urge to have a bowel movement. 46 Many over-the-counter weight loss preparations contain more than one ingredient. Following is an overview of some of the more common ingredients found in these preparations:

warm water before each meal. 47 Clinical trial is required to assess the efcacy of this product. Benzocaine-containing agents: These agents have a local anesthetic effect that numbs the oral cavity and decreases taste sensation. This activity may impair swallowing and increase the risk of aspiration. 46 Clinical trials are required to assess the efcacy of these products. Citrus aurantum: This agent, also called bitter orange, is found in many nonprescription weight loss products and most commercially available products contain from 1–6% synephrine. Some products containing bitter orange are boosted with extra synephrine to as much as 30%. Synephrine is a sympathetic alphaadrenergic agonist with properties similar to phenylephrine’s. This agent should be avoided, especially when other stimulants are used, as hypertension and cardiovascular toxicity may result.47 Health Canada has advised against using products containing synephrine. 48 Phaseolamin: Also known as white kidney bean extract, phaseolamin is theorized to inhibit the process of starch absorption by reducing activity of the enzyme amylase in the lumen. This prevents, or at least slows down, the absorption of glucose. Studies have concluded that most commercial preparations do not contain enough phaseolamin to enhance weight reduction, but larger evidence-based studies are required.46 Chitosan: This ingredient reportedly decreases the absorption of fat by binding to it. It also acts as a bre to increase satiety (feeling of fullness). Chitosan is derived from shellsh. Therefore, any allergic patients must be warned before choosing a product containing this agent. Recent studies suggest that chitosan is no better than placebo for helping people lose weight. Larger studies are required to validate these ndings. 46,47

There are many additional weight loss preparations available without a prescription. Ingredients include cayenne, pyruvate, country mallow, and fucus. The efcacy of these agents is not supported by good clinical trial data.

8. Physical activity and contribution to weight loss programs As discussed earlier, successful weight loss programs should consist of recognized diet, exercise, and behaviour-management strategies. Health Canada estimates that 25% of deaths due to cardiovascular disease are a direct result of sedentary living.49 Approximately two-thirds of Canadians do not

• Apple cider vinegar: This liquid likely contains some pectin and probably acts as a bulk-forming agent. Pectin may also delay gastric emptying and increase satiety. The typical dose of apple cider vinegar for weight loss is one ounce with one teaspoon of honey in 1–4 ounces of


9

meet the requirements of Canada’s Physical Activity Guide to Healthy Active Living. 47 The good news is that active living can be incorporated into daily life. Regular physical activity reduces risk for CAD by up to 50%. 50 Canada’s Physical Activity Guide is a comprehensive reference source for Canadians of all ages, with recommendations for types of activities and amount of exercise required to promote health improvement. It is readily available online at www.paguide.com (see below). Canada’s Physical Activity Guide recommends three general types of activities for optimal health. They include:

onstrated that a physical activity program in the workplace can reduce absenteeism due to illness, injury, and stress, and can improve overall productivity.51 Copies of Canada’s Physical Activity Guide to Healthy Active Living can be obtained by calling 1–888–334–9769 or can be downloaded online at www.paguide.com.

9. Pharmacists and weight management: drugs not required As accessible healthcare professionals and sources of patient support, pharmacists have much more to offer the overweight patient than just medications. Following are some ideas for helping your patients through the change process required for meeting weight management targets:

• Endurance activities (4–7 days per week): walk ing, golng, yard and garden work, cycling, skating, continuous swimming, tennis, dancing. › Use comfortable footwear that provides good cushioning and support. • Flexibility activities (4–7 days per week): gardening, yard work, vacuuming, stretching exercises, T’ai Chi, golf, bowling, yoga, curling, dancing. › Start with ve minutes of light activity (e.g., easy walking). › Stretch slowly and smoothly without bouncing or jerking. • Strength activities (2–4 days per week): lifting and carrying groceries, climbing stairs, abdominal curls and push-ups, wearing a backpack to carry weight, and adding strength training routines. › Start with ve minutes of light endurance activity and stretching at the beginning of each session. › Rest for at least one day between strengthtraining sessions › Learn proper technique to protect back and joints from undue stress.

• Make it known through your discussions with patients seeking help with weight management that you are available and accessible throughout the “journey.” • Simply having a corner where weigh scales, tape measures, BMI charts, and information about healthy lifestyle are available can be helpful to patients and let them know you are approachable on the subject. This approach also supplies an “opening” to conversation about this potentially delicate subject. • Individualize recommendations according to patient needs and circumstances but according to current guidelines. Make sure patients understand “what’s in it for them” to reach their targeted weight. The information digested from this continuing education lesson will allow you to explain clearly to patients why you are recommending “guideline” based management strategies. • Ensure that patients understand the key to success is in weight maintenance. In order to achieve this goal, diet and physical activity behaviour modications that can become part of daily living make the most sense. • Continue to monitor and encourage patients and ask them how they are doing with their plans and if you can help them with any concerns. • Research local guideline-based weight management support programs in your area. Examples include Weight Watchers (www.weightwatchers.ca) and the Body Wellness Program (www. bodywellnessprogram.com). Refer the patient to a local dietitian where appropriate. The Dietitians of Canada website has many healthy eating tips – see www.dietitians.ca/public/content/ eat_well_live_well/english/index.asp

Note: Golng, gardening and yard work, and dancing include both endurance and exibility components. Two-for-one activities! The goal of physical activity is to exercise for 60 minutes each day for periods of at least 10 minutes each. The amount of time required for benet depends on the effort. For example, moder ate-effort activities such as brisk walking, biking, raking leaves, or swimming may require 30–60 minutes daily to meet physical activity requirements, depending on the activity. 51 Pharmacists should educate patients on the benets of physical activity as part of a comprehensive weight management program. The benets extend far beyond losing weight. A study conducted by the Canada Life Assurance Company dem-


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Reerences

Diabetes Care 2004; 27 10:2444–2449. 15. Colditz GA, Willett WC, Rotnitzky A, Manson JE. Weight gain as a risk factor for clinical diabetes mellitus in women. Ann Intern Med 1995; 122 7:481–486. 16. Chan JM, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care 1994; 179:961–969. 17. Canadian Institute for Health Information. A matter of fact... Obesity and overweight in Canada. secure. cihi.ca/cihiweb/en/downloads/cphi_obesity_e.pdf. Accessed Nov 4, 2005. 18. The fast food nutrition fact explorer. www.fatcalories.com/. 2005. 19. Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of physical inactivity in Canada. cmAJ 2000; 163 11. 20. Jung RT. Obesity as a disease. Br Med Bull 1997; 532:307–321. 21. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346 6:393–403. 22. Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001; 34418:1343–1350. 23. Klein S, Sheard NF, Pi-Sunyer X, Daly A, WylieRosett J, Kulkarni K et al. Weight management through lifestyle modication for the prevention and management of type 2 diabetes: rationale and strategies: a statement of the American Diabetes Association, the North American Association for the Study of Obesity, and the American Society for Clinical Nutrition. Diabetes Care 2004; 27 8:2067–2073. 24. Health Canada. Canada’s Food Guide. www.hcsc.gc.ca/hpfb-dgpsa/onpp-bppn/food_guide_rainbow_e.html. 2005. 25. 25 Giles,T. Reducing the risk of cardiovascular events through weight loss. www.medscape.com/viewprogram/1870 Accessed Nov.7, 2005 26. Tsai AG, Wadden TA. Systematic review: an evaluation of major commercial weight loss programs in the United States. Ann Intern Med 2005; 142 1:56–66. 27. Freedman MR, King J, Kennedy E. Popular diets: a scientic review. Obes Res 2001; 9 Suppl 1:1S-40S. 28. Foster GD, Wyatt HR, Hill JO, McGuckin BG, Brill C, Mohammed BS et al. A randomized trial of a lowcarbohydrate diet for obesity. N Engl J Med 2003; 34821:2082–2090. 29. Samaha FF, Iqbal N, Seshadri P, Chicano KL, Daily DA, McGrory J et al. A low-carbohydrate as compared with a low-fat diet in severe obesity. N Engl J Med 2003; 348 21:2074–2081. 30. South Beach Diet: Dr. Agatston’s South Beach Diet Plan. www.diet-i.com/south-beach-diet.htm.

1. Agriculture FaRDAG. Consumer food trends - Canadian consumer trends in obesity and food consumption. www1.agric.gov.ab.ca/$department/deptdocs nsf/all/sis8438. Accessed October 12, 2005 2. Anderson RE. The spread of the childhood obesity epidemic. cmAJ 2000; 163 11. Available online at www. cmaj.ca/cgi/content/full/163–11/1461-. Accessed Nov. 4, 2005. 3. Katzmarzyk PT. The Canadian obesity epidemic, 1985–1998. cmAJ 2002; 166 8:1039–1040. 4. National Heart Lung Blood Institute. The Practical Guide: Identication, Evaluation, and Treatment of Overweight and Obesity in Adults. www.nhlbi.nih. gov/guidelines/obesity/practgde.htm. Accessed Oct 10, 2005. 5. Health Canada: Ofce of Nutrition Policy and Promotion. Canadian Guidelines for Body Weight Classication in Adults - Quick Reference Tool for Professionals. www.hc-sc.gc.ca/hpfb-dgpsa/onppbppn/cg_quick_reference_e.html 2005. 6. Yusuf S, Hawken S, Ounpuu S, Bautista L, Franzosi MG, Commerford P et al. Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case-control study. Lancet 2005; 366(9497):1640–1649. 7. Health Facts of Obesity. American Obesity Association 2005. Available online a t www.obesity.org/ subs/fastfacts/Health_Effects.shtml. Accessed Nov. 7, 2005. 8. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Denition, classication and diagnosis of diabetes and other dysglycemic categories. Can J Diabetes 2003; 27 (s uppl 2):S7-S13. 9. Blackburn GL. The obesity epidemic: Prevention and treatment of the metabolic syndrome. www.medscape.com/viewprogram/2015_pnt.2003. Accessed Oct 10, 2005. 10. Fodor JG, Frohlich JJ, Genest JJ, Jr., McPherson PR. Recommendations for the management and treatment of dyslipidemia. Report of the Working Group on Hypercholesterolemia and Other Dyslipidemias. cmAJ 2000; 16210:1441–1447. 11. The IDF consensus woldwide denition of the metabolic syndrome. www.idf.org/webdata/docs/ IDF_Metasyndrome_denition.pdf. Accessed Oct 10, 2005 . 12. Ford ES, Giles WH. A comparison o f the prevalence of the metabolic syndrome using two pro posed denitions. Diabetes Care 2003; 26 3:575–581. 13. Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults: ndings from the third National Health and Nutrition Examination Survey. JAMA 2002; 287 3:356–359. 14. Ford ES, Giles WH, Mokdad AH. Increasing preva lence of the metabolic syndrome among u.s. Adults.


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Accessed Oct 12, 2005. 31. Canadian Broadcasting Corporation. The Bernstein Diet: How much weight should you give celebrity endorsements? www.cbc.ca/consumers/market/ les/health/bernstein_diet/index.html. Accessed Oct 11, 2005. 32. Anderson JW, Konz EC, Jenkins DJ. Health advan tages and disadvantages of weight-reducing diets: a computer analysis and critical review. J Am Coll Nutr 2000; 19 5:578–590. 33. Bowman SA, Spence JT. A comparison of low-carbohydrate vs. high-carbohydrate diets: energy restriction, nutrient quality and correlation to body mass index. J Am Coll Nutr 2002; 21 3:268–274. 34. Ionamin product monograph. Compendium of Pharmaceuticals and Specialties 2005. 35. Sanorex product monograph. Compendium of Pharmaceuticals and Specialties 2005. 36. Tenate Dospan product monograph. Compendium of Pharmaceuticals and Specialties 2005. 37. Campbell ML, Mathys ML. Pharmacologic options for the treatment of obesity. Am J Health Syst Pharm 2001; 5814:1301–1308. 38. Sjostrom L, Rissanen A, Andersen T, Boldrin M, Golay A, Koppeschaar HP et al . Randomised placebo-controlled trial of orlistat for weight loss and prevention of weight regain in obese patients. European Multicentre Orlistat Study Group. Lancet 1998; 352(9123):167–172. 39. Davidson MH, Hauptman J, DiGirolamo M, Foreyt JP, Halsted CH, Heber D et al. Weight control and risk factor reduction in obese subjects treated for 2 years with orlistat: a randomized controlled trial. JAMA 1999; 2813:235–242. 40. Hauptman J, Lucas C, Boldrin MN, Collins H, Segal KR. Orlistat in the long-term treatment of obesity in primary care settings. Arch Fam Med 2000; 9 2:160– 167. 41. Li Z, Maglione M, Tu W, Mojica W, Arterburn D, Shugarman LR et al. Meta-analysis: pharmacologic treatment of obesity. Ann Intern Med 2005; 142 7:532– 546. 42. Xenical product monograph. Compendium of Pharmaceuticals and Specialties 2005. 43. Torgerson JS, Hauptman J, Boldrin MN, Sjostrom L. XENical in the prevention of diabetes in obese sub jects (XENDOS) study: a randomized study of orlistat as an adjunct to lifestyle changes for the prevention of type 2 diabetes in obese patients. Diabetes Care 2004; 271:155–161. 44. Meridia product monograph. Compendium of Pharmaceuticals and Specialties 2005. 45. Fujioka K. Management of obesity as a chronic disease: nonpharmacologic, pharmacologic, and surgical options. Obes Res 2002; 10 Suppl 2:116S-123S. 46. Heschuk S. Weight Management. In: Repchinsky C, editor. Patient Self-Care. Ottawa: Canadian Pharma-

cists Association, 2002: 376–390. 47. Eidsness MN. Nonprescription weight loss pro ducts and supplements: A review. Pharmacy Practice Journal 2003; October supplement. 48. Health Canada. Health Canada Warns Canadians not to use “Thermonex”. www.hc-sc.gc.ca/ahcasc/media/advisories-avis/2004/2004_30_e.html. Accessed Nov 7, 2005 . 49. Canada’s Physical Activity Guide. www.paguide. com 2005. 50. Health Canada. Canada’s Physical Activity Guide. www.paguide.com. Accessed Nov 7, 2005 . 51. Canada’s Physical Activity Guide. www.paguide. com 2005.


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Questions

5. Which of the following statements about visceral fat is false? a. Visceral fat produces and secretes inamma tory cytokines that can block the actions of insulin. b. Visceral fat may set off a series of reactions that result in larger LDL particles. c. Visceral fat causes increased levels of free fatty acids which in turn can cause elevated rate of gluconeogenesis in the liver. d. Excess visceral fat leads to slower VLDL clearance.

The questions below refer to the following scenario: RM is a 42-year-old man who has a BMI of 32 kg/ m², a waist circumference of 110 cm, and has been recently diagnosed with hypertension. His doctor would like him to try lifestyle management before turning to medication for lipid control. 1. Which one of the following statements about overweight and obesity in Canada is false? a. The number of obese adults in Canada almost tripled in one recent 15-year period. b. About one-fth of Canadian adults are either overweight or obese. c. Excess weight among male children almost doubled in the 15 years leading up to 1996. d. Almost one-quarter of female children were overweight in 1996.

6. Which of the following can you tell RM would be a benet of losing 10 kg body weight? a. Reduction of blood pressure by approximately 10/20 mmHg. b. Reduction of total cholesterol by approximately 30%. c. Reduction of LDL cholesterol by approximately 30%. d. Both a and c.

2. In view of RM’s BMI, what is his risk of developing health problems according to Health Canada guidelines for body weight classication? a. increased b. high c. very high d. extremely high

7. RM has a family history of type 2 diabetes and tells you his latest fasting blood glucose was 6.3 mmol/L. He wants to know if diabetes can be averted. Which one of the following answers would be most appropriate in his circumstances? a. Studies show becoming more physically active and losing weight will prevent type 2 diabetes in close to 100% of cases. b. Type 2 diabetes is a journey which can only be delayed but never prevented. c. Losing weight and becoming more physically active signicantly reduces risk for getting type 2 diabetes. d. Metformin treatment is necessary for prevention of diabetes, in addition to weight loss and increased physical activity.

3. Which of the following statements about RM’s health status is true? a. He has metabolic syndrome since he is obese and has hypertension. b. He is not at increased risk for type 2 diabetes compared to a non-obese person. c. He is at increased risk for dyslipidemia because he is obese. d. Both a and c are true. 4. Which of the following risk factor parameters are the same for both the NCEP and the new proposed IDF denitions of metabolic syndrome? a. Both require a waist circumference of ≥88 cm for women. b. Both list a blood pressure of ≥140/90 mmHg as one of the qualiers for metabolic syn drome. c. Both list a fasting plasma glucose of ≥6.1 mmol/L as one of the qualiers for metabolic syndrome. d. Both list a triglyceride level of ≥1.7 mmol/L as one of the qualiers for metabolic syn drome.

8. RM wants to know how to lose weight sensibly. Which of the following recommendations is most appropriate? a. Try to expend 500–1000 calories more per day than you ingest. b. Target 3 kg per week weight loss. c. Aim for taking off targeted weight by the end of 3 months. d. Answers a and c are correct. 9. Approximately how many daily calories should generally be recommended per day for men in RM’s circumstances who want to lose weight? a. 1000 calories b. 1500 calories c. 2000 calories d. 2500 calories


13

10. What percentage of calories should carbohydrate make up for someone wanting to lose weight according to recommended guidelines? a. 25% b. 35% c. 45% d. 55%

15. The Bernstein Diet is another consideration. Which of the following statements about the Bernstein Diet is true? a. The Bernstein Diet allows for better weight maintenance than guideline-based diets. b. The Bernstein Diet is based on a calorie intake of approximately 1400 calories daily for women. c. People using the Bernstein Diet take off approximately 2 kg per week on average in the initial phases. d. The Bernstein diet is associated with less nausea and lightheadedness than guidelinebased diets due to supplementation with vitamin injections.

11. RM wants to know more about bre. Which of the following statements about bre is true? a. A good source of bre is simple sugars. b. Fibre intake should not exceed 10 grams daily. c. Fibre promotes a feeling of “fullness” at lower levels of calorie intake. d. Both answers b and c are correct.

16. RM just wants to know what the best weight loss program is. Which of the following principles is false? a. A low-fat diet containing 1500 calories will take weight off more quickly than a guideline-based diet containing 1500 calories. b. Guideline-based diets would reduce serum cholesterol more effectively on average than the Atkins Diet. c. The Protein Power Diet has the potential to signicantly increase serum cholesterol with long-term use. d. Answers b and c are both false.

12. RM says he is considering entering a dieting program. Which one of the following most closely approximates principles aligned with guidelinerecommended strategies? a. Dr. Dean Ornish’s program b. Protein Power c. Weight Watchers d. Bernstein Diet 13. RM is interested in the South Beach Diet because Bill Clinton had success with it. Which of the following statements about the South Beach Diet is true? a. The South Beach Diet is a very-low-calorie diet. b. People on the South Beach Diet spend approximately the rst two weeks on a lowcarbohydrate diet. c. The South Beach Diet is a classic low-fat diet. d. The South Beach Diet stresses high protein intake (~ 40%) as a critical part of the program.

17. You mention to RM that there are medications available for weight loss. You know RM meets the criteria for pharmacological management because: a. he is over 40 and weighs over 27 kg/m² b. hny patient meets the labelled indications for orlistat or sibutramine as long as they are motivated to lose weight c. he has a waist circumference greater than 102 cm d. he has a BMI of 30 or greater and has had little success with lifestyle changes alone

14. RM also wants to know about the Atkins Diet. Which one of the following statements about the Atkins diet is false? a. The initial weight loss occurring with the Atkins diet is related to water loss. b. The Atkins diet is a classic low-carbohydrate diet. c. In a clinical study published in the New England Journal of Medicine, people on the Atkins Diet showed faster rate of weight loss in the rst 2–6 months. d. In a clinical study published in the New England Journal of Medicine, people on the Atkins Diet showed better overall weight loss after 12 months.

18. RM comes back one month later with a prescription for orlistat. What have clinical trials shown the average weight loss to be after one year of therapy with orlistat? a. 1–2 kg b. 2–3 kg c. 3–4 kg d. 4–5 kg 19. Which of the following statements about orlistat is not true? a. Patients taking the drug should take a multiple vitamin daily. b. Orlistat has been shown to reduce the incidence of diabetes in obese patients. c. Orlistat clinical studies show that weight loss


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continues for at least two years if the drug is continued. d. Orlistat inhibits dietary fat absorption by about 30%.

26. Which of the following nonprescription products must be avoided in the presence of seafood allergy? a. phaseolamin b. benzoocaine c. bitter orange d. chitosan

20. RM’s friend took phentermine about 10 years ago and shed pounds fast. Which of the following statements about phentermine is false? a. Constipation is a common side effect. b. Maximum indicated time to be on the drug is one year. c. Diethylpropion works with similar mechanism of action. d. It is contraindicated in people with severe hypertension.

27. RM wants to become more active. Which of the following motivators would be appropriate for discussion with RM? a. He can join the more than two-thirds of Canadians who meet the physical activity requirements of Canada’s Physical Activity Guide. b. He can reduce his risk for coronary artery disease by up to 50%. c. If he exercises, he won’t be among the 10% of Canadians dying from cardiovascular disease as a direct result of sedentary living. d. Although joining a gym or similar program is mandatory, the benets of regular physical activity are immense.

21. Which of the following products has been linked to increased risk for cardiac valve disease? a. sibutramine b. orlistat c. fenuramine d. answers a and c 22. Which of the following is not a contraindication to sibutramine use? a. bipolar disorder b. heart failure c. blood pressure greater than 145/90 mmHg d. patients taking 7-day course of erythromycin

28. Which of the following activities would be most appropriate to benet RM in addition to his diet? a. endurance activities 6 days a week, exibility activities 2 days a week, and strength activities 5 days a week b. endurance activities 6 days a week, exibility activities 6 days a week, and strength activities 3 days a week c. endurance activities 3 days a week, exibility activities 5 days a week, and strength activities 5 days a week d. endurance activities 6 days a week, exibility activities 6 days a week, and strength activities 6 days a week

23. Which of the following statements about sibutramine and orlistat is false? a. The drugs are similar in their capacity to promote weight loss after one year. b. Both are effective as an adjunctive treatment for patients with diabetes to improve blood glucose control. c. Both are approved for long-term weight loss management. d. Sibutramine is contraindicated for use in people with controlled hypertension.

29. What is the principle reason for declining recommended daily energy intake as we grow older? a. As we get older, our resting metabolic rate declines. b. As we get older, we tend to eat more. c. As we get older, we don’t remain as physically active. d. As we get older, our fat intake increases, so calories must be reduced to compensate.

24. RM tells you he has taken over-the-counter products in the past without much success. Which of the following agents is an alpha-adrenergic agonist? a. apple cider vinegar b. cayenne c. citrus aurantum d. fucus

30. What is the most common problem with commercial weight management programs? a. Patients become frustrated with the length of time needed to lose weight. b. Patients feel isolated in their ght against extra weight. c. Weight loss is difcult to maintain. d. None of the above are correct.

25. Which of the following statements about laxatives is false? a. Laxatives promote weight control by causing food to pass through the GI system more quickly. b. Laxatives do not promote weight loss.


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obesity

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