This question is meant to evaluate yourself before discussing the condition of obesity. If you are classified as obese, then cur te ipsum (Latin meaning “Take care of your own self” or “Cure your self) before dealing with patients.

Obesity is a condition of excess body fat accumulation resulting from a state of positive energy balance due to energy intake exceeding energy expenditure (i.e., calories in vs calories out). 

Evolution favored “feast and store” genes to survive long periods of minimal calories— now we live in an environment of high caloric food availability.

Define basal metabolic rate (BMR). What bodily processes does it include? Why is it important in the regulation of energy balance and body composition? Clinically, how is BMR measured? According to the Harris-Benedict Equation, what factors influence BMR? 

-Sedentary: 1547.9 x 1.2 =1857.5 kcal/day

-Moderately active: 1547.9 x 1.55 =2397.9 kcal/day

-Difference = 540.5 kcal/day
-7 x 540.5 =3782.8 kcal ÷ 3,500 = 1.1 lbs/week 

-The thermic effect of food (TEF) is the energy expended above RMR following food intake and accounts (metabolic cost of absorbing, transporting and converting the ingested nutrients into their respective storage forms) for approximately 10% of an individual’s total energy expenditure;

-Foods high in proteins and “complex carbohydrates” (fresh fruit and vegetables) have a high TEF;
-Fats and process food have a low TEF.

Given that thermogenic effect of physical activity (TEPA) is physical and muscular activity, some people are sedentary and some are very active—which accounts for the variability. 

Which two areas of the brain are considered the main controls for energy homeostatsis and the regulation of body weight? 

The ventromedial hypothalamus (VMH) nucleus and the lateral hypothalamus (LH) nucleus/ 

Which part of question #10 is the Satiety center? Hunger center? Which one, if stimulated, would cause hyperphagia? Inhibition of food intake? 

-The LH nucleus is the hunger center and the VMH nucleus is the satiety center;

-Stimulation of LH nucleus would cause hyperphagia (over eating or eating more that is needed to support caloric needs);
-Stimulation of the VMH nucleus would result in inhibition of food intake. 

Cholecystokinin (CCK)

Leptin 

Leptin 

Blood concentrations are lowest shortly after a meal, then rise during the fast prior to the next meal. 

Ghrelin

An episodic signal that stimulates insulin secretion in response to a meal and stimulates the satiety center in the hypothalamus 

Glucagon-like peptide-1 (GLP-1) 

Leptin 

Ghrelin

Similar actions to CCK and GLP-1 in that it inhibits gastric emptying postprandially and suppresses appetite. 

Peptide YY

-Studies of obese children show that in 72% of cases at least one parent was obese;

-Adoptees were found to have a BMI similar to that of their biologic parents rather than their cultural parents;
-The BMIs of monozygotic twins resembled each other more closely than those of dizygotic twins, regardless of their rearing. 

What demographic data collected since the 1960’s strongly suggests that there are more than just genetics involved obesity within the United States? 

-Genetics cannot explain the dramatic increase in overweight and obese citizens in the United States over the short 40 year span from the 1960s to the beginning of the 21st century;
-Given all the cultures residing in the United States (Hispanic, Asian, American Indian, European), we have the highest percentage of obese citizens when compared to all of the industrial countries in the world.

What is unique about the United States that also established that there is more than just genetics involved in obesity? 

In the United States, is there a relationship between socioeconomic level and obesity when considering all women? Caucasian females? Hispanic/Latino females? Non-Hispanic Blacks/African Americans females? 

-When considering all women in the US, women in the higher socioeconomic level tend to have lower obesity percentage rates.
-However, these differences become significant for the Caucasian (white, non-hispanic) in that poorer women have much higher levels of obesity;

-For Hispanic/Latino females, poorer women tend to have higher obesity rates;

-For non-Hispanic/African American females, no differences exist. 

What ethnicity has the highest poverty rate in the United States? What ethnicity, no matter the age or gender, has the highest prevalence of obesity? 

-Non-Hispanic/African American

-Non-Hispanic/African American 

Define overweight in terms of BMI; Obesity; What anatomical site should you use to guide you in measuring waist circumference? With a BMI of 25 to 34.9, at what BMI does waist circumference lose its predictive power? 

-Overweight BMI = 25-29.9
-Obesity BMI = >30;
-Top of iliac crest;
-A waist circumference greater than 40 inches in men and 35 inches in women 

What BMI is the cut off as the definition of “extreme obesity” and carries with it extremely high disease risk factors? 

Why characteristic of excessive fat/adipose tissue is thought to directly contribute to the cardiovascular and metabolic risks associated with obesity? 

Adipocytokines, the bioactive products of adipose tissue and the macrophages that reside in this tissue, are now believed to play a significant role in cardiovascular and metabolic risk factors associated with obesity. 

What are the two ways by which exercise increases total body expenditure? In terms of lifestyle, what must exercise become in order to “keep the weight off”; Is there any benefit of obese individuals if exercise does not caused a decrease in weight loss? 

-the direct caloric cost of the exercise;

-the elevation of energy expenditure during the immediate post exercise period (i.e., excess post exercise consumption or EPOC).

-A daily habit;

-Yes, improves blood glucose level by increasing insulin sensitivity. 

What are the two classes of drugs that reduce energy intake? What is their common mode of action? What are their side effects separately and in combination (e.g., fen-phen)? 

• -Noradrenergic and serotonergic agents;

• -Induce anorexia through a centrally mediated pathway in the hypothalamus;

• - noradrenergic class side effects include insomnia, anxiety, irritability, and headache; serotonergic agents alone and in combination noradrenergic agents (fen-phen) were associated with valvular heart disease and pulmonary hypertension. 

What action does Orlistat (Xenical) have and, therefore, how is it thought to cause weight loss? What are its side effects? 

• -Orlistat (Xenical) inhibits the action of pancreatic lipases, thereby preventing the breakdown of dietary triglycerides into free fatty acids and thus prevents the absorption of dietary triglycerides;

• -Flatus and steatorrhea. 

How do agents in the thermogenic class of drugs increase energy expenditure? Why has the FDA ruled in prohibiting the sale of dietary supplements containing ephedrine alkaloids? 

• -Ephedrine has been linked to significant adverse health outcomes, including heart attack and stroke. 

Although both types of bariatric surgery for obese persons studied in this section (Rouxen-Y and Laparoscopic adjustable gastric band surgery) are used to reduce the size of the stomach, differentiate between the manner in which this is accomplished. 

• -Gastric bypass surgery reduces the stomach to a small pouch and re-routing it to a more distal portion of the small intestine;

• -Laparoscopic adjustable gastric band surgery involves placing a band around the upper stomach near the esophagus, restricting the quantity of food that can enter the stomach). 

Using the diagram below, which frame identifies a Roux en-Y proximal gastric bypass? A Roux en-Y distal gastric bypass? 

-Distal Roux en-Y;
-Modest increase in total weight loss 

1.  (a) Malabsorption of calories contributes to weight loss.
2. (b) Because of the limited size of the stomach, the patient cannot eat a lot of food at one time and is put on a mealtime schedule of 5 to 6 small meals daily.
3. (c) The operation completely counteracts the adverse effects of destructive eating behavior.
4. (d) The patient cannot graze between meals.

Anastomotic ulcer 

Dumping syndrome 

Roux en-Y Surgery 

Nutritional deficiencies 

An inflatable silicone device that is placed around the top portion of the stomach. 

2. Laparoscopic adjustable gastric band 

Causes reduced absorption (malabsorption).

Erosion of the stomach wall

2. Laparoscopic adjustable gastric band 

Uses a small access port placed just under the skin for adjustments. 

2. Laparoscopic adjustable gastric band 

The operation completely counteracts the adverse effects of destructive eating behavior. 

Neither a characteristic of Roux en-Y surgery or laproscopic adjustable gastric band 

Anastomotic stricture

Creation of a small (1-2 tbsp) thumb-sized pouch from the upper stomach, accompanied by bypass of the remaining stomach. 

Roux en-Y Surgery 

Anastomotic leakage

Roux en-Y Surgery 

Productive Burping

2. Laparoscopic adjustable gastric band 

Weight regain is possible

2. Characteristic of both 

Re-construction of the gastrointestinal (GI) tract so that a segment of the small intestine is brought up to the proximal remains of the stomach. 

Roux en-Y Surgery 

Restricts the volume of food which can be eaten. 

2. Characteristic of both