The BMR is then multiplied by an activity factor to arrive at total energy expenditure: 1.2, sedentary; 1.375, mild activity; 1.55, moderate activity; 1.7, heavy activity; 1.9, extreme activity.
For office purposes it may be more efficient to arrive at a reasonable estimate by first determining the ideal body weight (IBW) based on height:
Once IBW is determined, it can be multiplied by 12–13 for women and 13–15 for men to arrive at a reasonable goal for daily caloric intake .
7.3 Assessing Weight Loss
Once a patient begins on their weight-loss journey (whether it be through medical or surgical intervention), it is imperative to track their progress. Journals are highly recommended to track patient’s activity and dietary habits as well as their progress. While overall weight loss is an important metric, percent of excess weight loss (%EWL) is more pertinent and can be calculated as:
7.4 Nonsurgical Interventions for Weight Loss
Successful weight loss must start with a multimodal approach including diet, exercise, and behavioral modification. A full history and physical should include :
History of weight gain and loss
Medications which contribute to weight gain (steroids, antipsychotic agents)
Previous attempts at weight loss
Patterns of food intake
Physical activity levels
Patients with a BMI <35 should seek to reduce their caloric intake by 500 kcal/day. This will generally result in loss of 1 pound per week and a 10 % weight reduction in 6 months. If the BMI is >35, a reduction of 500–1000 kcal/day should be sought to achieve weight loss of 1–2 pounds per week. Currently a low-carbohydrate, high-protein diet is recommended as protein is thought to increase satiety . Other recommendations to increase satiation include encouragement of five small meals per day and chewing food 20–30 times per bite. Protein supplements can be used as meal replacements.
A high volume and physical intensity level of exercise is required to induce weight loss; however, it should be encouraged in all patients who are physically able and plays a large role in long-term weight management. A journal should be established to track the patient’s progress. An exercise “prescription” can be given to the patient based on the FITT (frequency, intensity, time, and type) principle. Special considerations must be taken when prescribing exercise programs to obese and should take into account their cardiovascular, pulmonary, and musculoskeletal status. Adjuncts such as aquatic exercise programs have proven successful in reducing musculoskeletal complications which can limit an obese patient’s ability to comply with an exercise program . Sixty to ninety minutes per day of moderate-to-vigorous intensity physical activity is suggested to maintain weight loss .
7.4.3 Behavioral Therapy
Personal, psychological, and social cues contribute greatly to our eating habits and often impede long-term weight-loss success. Strategies of behavior control include avoiding stimuli that lead to eating, activity, and consumption logs to help identify these cues and social support. Group therapy has proven successful and should be continued long term .
7.4.4 Pharmacological Therapy
Indications for consideration of pharmacological therapy for weight loss include BMI >30 and BMI >27 with the presence of an obesity-related complication including type 2 diabetes, hypertension, and dyslipidemia . Many medications have been withdrawn because of side effects. Currently approved drugs include :
Orlistat – inhibits gastric and pancreatic lipases limiting the digestion and absorption of fat. It is recommended for use for up to 6 months along with a weight-loss program. There is an over-the-counter formulation sold as Alli. Side effects include fatty/oily stool, fecal urgency and incontinence, flatulence, and decreased absorption of fat-soluble vitamins.
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