WEIGHT LOSS, EATING

DISORDERS AND OBESITY

Dr. Maria Honolina S Gomez, MD, FPCP, FPSEM, FACE
Section of Endocrinology, Diabetes and Metabolism
By: Thea C. Marcelo Sec C 2014

LEARNING OBJECTIVES:
1. To discuss the anthropometric
measurements
2. To differentiate VOLUNTARY from
INVOLUNTARY weight loss
3. To define and describe eating disorders
EQUIPMENT

Standing platform scale with height

attachment

Skinfold thickness calipers

Measuring tape, non-stretching

Infant scale

Recumbent
measuring device
(for infant)

Stature measuring
device (for children)
ANTHROPOMENTRIC
MEASUREMENTS

Height or length

Weight

Mid-upper arm
circumference (MAC)

Demi-span or arm span

Knee height

Sitting height

Skinfold thickness

Head circumference

Weight
A portable scale with a 125 kg maximum
capacity and a +/- 100g error margin is
used
Individuals remove shoes and heavy
cloths prior to weighing
What to do if not able to weigh in
properly?
Assess in change of clothing size
Corroborate weight loss with
relative or friend
The numerical estimate of weight
loss provided by the patient are
suggestive enough of true weight
loss
Knee Height
Correlated with stature

Height

The preferred method in estimating

height in bedridden patients
Measured using a sliding broad-plane
caliper
While lying supine, asked to bend both
left knee and ankle at 90. Fixed blade
under the heel of left foot while sliding
blade pressed down against thigh about
5.1cm proximal to knee cap.
Shaft of caliper in line with long bone
(tibia) in lower leg and over ankle bone
(lateral malleolus).
Locking lever pushed away from blades
to hold measurement and read thru
viewing window to nearest 0.1cm.
2 measurements made in succession
which should agree within 0.5cm.

Assessing Height and Weight

Current weight

Current height

Usual weight
Desirable body weight: Tanhausers
or Hamwis method
% desirable body weight : current
weight x 100
desirable body

wt

% usual weight : current weight x 100

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

Adjustment for Amputation

Subtract the percentage weight
contributed by amputated body parts
Trunk without limbs 42.7%
Entire upper extremity 6.6%
Hand 0.8%
Forearm 2.3%
Upper arm 3.5%
Entire lower extremity 18.7%
Foot 1.8%
Lower leg 5.3%
Thigh 11.6%
Paraplegia subtract 5-10% from calculated
DBW
Quadriplegia subtract 10-15% from calculated
DBW

Ensure not to contract gluteal muscles or

push with legs
Record measurement at the end of deepinward breath record at nearest 0.1cm

Method for determining frame size

1. Elbow Breadth measurement
Extend right arm and flex elbow at 90
Thumb pointing up with palm turned
laterally
Face patient and put caliper between
two most prominent bones of elbow
2. Wrist Circumference
A persons height and the measure of his
wrist determines body frame size
-

Determining body frame size with wrist

circumference ratio:
HEIGHT (cm) / WC (cm)

Frame Size
SMALL
MEDIUM
LARGE

Ratio for Men

<9.6
9.6 - 10.4
>10.4

Ratio for
Women
<9.9
9.9 10.9
>10.9

Body Mass Index

Measure of body fat in adults to help
assess whether one is at risk of weightrelated problems
BMI = Wt in kg / Ht in m2

Arm Span
Procedure: face away form wall, with
back and buttocks touching, the arms are
stretched out horizontally. Measure from
tip ( 3rd finger) to the other
Results: Arm span = height
Arm length = arm span
shoulder width
Exemptions: Marfans syndrome
Sitting Height
Stretch stature method
Maximum distance: vertex to the base of
sitting surface
Seat subject on a measuring box or level
platform (of known height) with their
hands resting on their thighs
Instruct subject to take and hold deep
breath
Place headboard firmly down the vertex,
crushing hairs as much as possible

Do NOT apply to children, pregnant

women, people with muscular build (little
body fat) eg. athletes

Waist Circumference
The plane between umbilical scar and
inferior rib border
NO holding your belly in!
Midway between uppermost border of
iliac crest and lower border of costal
margin (ribcage)
Tape is snug but does not compress skin

WHO Asians
WHO
Caucasians

MEN
>35 in
(90cm)
>40.0

WOMEN
>31 in (80cm)
>35.0

Hip Circumference
Stand erect with weight evenly
distributed on both legs, legs slightly
parted, with arms resting by the side,
making sure not to tense gluteal
muscles
HC measured from the maximum
perimeter of buttocks
Tape not too tight or too loose, lying
flat
Waist-Hip Ratio
Measures proportion by which fat is
distributed around the torso
WHO: >0.7 for women
>0.9 for men
-

Apple type more susceptible to DM, CV

disease, ovarian and prostate CA more
wt above waist
Pear type more wt below waist
(better)

NUTRITIONAL STATUS
1. Triceps Skin fold
Person stand upright with arms
hanging down loosely
Skinfold pulled away from muscle and
measured with calipers, taking a
reading 4 secs after calipers are
released
The measuring point is halfway
between olecranon process of the ulna
and acromion process of scapula
Decreased TSF = decreased fat stores
due to long term undernutrition

Circumference of upper arm at the

same midpoint, measured with nonstretchable tape measure
Used to determine subcutaneous or fat
loss
Reflects the skeletal mass status of
patient

MICRONUTRIENTS: Clinical Indications

Pallor of palms or inside of eyelids and

mouth Iron deficiency Anemia

Night blindness (inability to see in low

light) Vitamin A deficiency

Bitots spot (spots on whites of eyes)

Vitamin A deficiency
Goiter (enlargement of thyroid)
Iodine deficiency
Hair fall in women Zinc deficiency

Physical Findings of Nutritional

Deficiencies
1. Vitamin C
Corkscrew hairs
Unemerged coil hairs
Petechiae (esp perifollicular)
Swollen retracted gum bleed
2. Vitamin C and A
Follicular hyperkeratosis
3. Vitamin C and K
Purpura
4. Niacin
Pigmentation, scaling of sun exposed
areas

2. Mid-upper Arm Circumference

5. Protein
Easily pluckable hair
Flag sign (transverse hair
depigmentation)
Sparse hair (together with zinc)
Transverse ridging of nails

Cellophane appearance
Cracking (flaky paint or crazy
pavement dermatosis)
Parotid enlargement also consider
bulimia

6. CHON, Vit C, Zinc

Pour wound healing
Decubitus ulcer
7. Vitamin A
Night blindness
Papilledema
8. Riboflavin, Pyridoxine, Niacin
Angular stomatitis
Cheilosis (dry, cracking ulcerated lips)
9. Riboflavin, Pyridoxine, Niacin,
Folate, B12
Glossitis (scarlet, raw tongue)
10. Riboflavin, Niacin, Folate, B12,
Protein, Iron
Atrophic lingual papillae (slick tongue)

11. Zinc
Hypoeusethesia, hyposmia
12. Protein, Thiamine
Edema

4.5 Kg ( 10 lb), or more than 5% of

baseline body weight over a period of 612 months

HPI: Weight Loss

Total weight loss: compared with usual

weight, time period (sudden or gradual,
desired or undesired)

Desired weight loss: eating habits, diet

plan used, MNT, food preparation, food
group avoidance, exercise pattern, target
goal

Undesired weight loss: anorexia,

vomiting, diarrhea, frequent urination,
excessive thirst, change in lifestyle,
stress levels

Preoccupation with oneself, unusual food

restrictions or cravings, laxative abuse,
induce vomiting, amenorrhea, excess
exercise

Medication: chemotherapy, OHA, insulin,

fluoxetine, diuretics, nonprescription
appetite suppressants, herbal
supplements
Major causes of Weight Loss

Voluntary (desired)
May not be a matter of concern in an
overweight patient who is dieting but
can be a manifestation of psychiatric
illness
1.

13. Thiamine (Wet Beriberi),

Phosphorous, Protein, Vit A
hepatomegaly

2.
WEIGHT LOSS
It is the reduction of the total body
weight due to a near loss of fluid body fat
or adipose tissue and/or lean mass
usually bone mineral deposits, muscle,
tendon and other connective tissue.
Significant Weight Loss
1.0% - 2.0% in one week
5.0% in one month
7.5% in 3 months
10.0% in 6 months

3.
4.

1.

Treatment of obesity
Sibutramine causes heart
disease
Rimonaban suicidal
tendencies
Anorexic drugs
Amphetamine
Thyroid hormone
Anorexia nervosa & Bulimia
Distance runners, models, ballet
dancer, gymnasts
Involuntary (undesired)
With decrease or increase appetite is
nearly always a sign of a serious
medical or psychiatric illness
With increased appetite
Hyperthyroidism (Graves)
Hyperdefacation
Heat intolerance

2.

Uncontrolled Diabetes
Uncontrolled - blood glucose
greater than 180mg (renal
threshold for glucose) -->
polyuria -->
Dehydration
Weight loss is a sign of poorly
controlled DM
Malabsorption syndrome
Pheochromocytoma
marked increase in physical activity

With decreased appetite

Medical disorders
o Malignancy
particularly GI, lung,
lymphoma, renal, prostrate
o Endocrinopathies
adrenal insufficiency
(especially in those chronic
users of steroids; usual clue
= fatigue)
o Chronic illness
Severe heart, lung or kidney
diseases - cardiac cachexia
(fatigue from eating, even
walking), pulmonary cachexia
(widened ICS, tripod), renal
failure, nephrotic syndrome,
chronic glomerulonephritis
o Infectious diseases
hepatitis (fever followed by
loss of appetite),
tuberculosis, fungal or
bacterial diseases, chronic
helminth infection
o COPD
o Gastrointestinal disease
peptic ulcer diseases,
diabetic enteropathy,
dysphagia, malabsorption,
inflammatory bowel diseases,
hepatitis, Zenker's
diverticulum, paraesophageal
hernia
Psychiatric disorders
o Depression
o Manic phase of manicdepressive
o Personality disorder
o Paranoid or delusional
Chronic Drug Use

o
o
o
o
o

alcohol
opiates
amphetamines
cocaines
others (tropimate, exenatide,
metformin, serotonin uptake
inhibitors, NSAID)

EATING DISORDERS
group of serious conditions in which a
person is preoccupied with food and
weight that he/she can focus on little
else.
Types:
Anorexia Nervosa
Bulimia Nervosa
Binge-eating Disorder
Red Flags to indicate Eating Disorder

Skipping meals

Making excuses for not eating

Eating only safe foods, low in fat and

calories

Adopting rigid meals or eating rituals

(cutting food into tiny pieces or spitting
food out after chewing)

Cooking elaborate food for others but

refusing to eat it themselves

Collecting recipes

Withdrawing from normal social

activities

Persistent worry or complaining about

being fat

A distorted body image such as

complaining about being fat despite
being underweight

Not wanting to eat in public

Wearing baggy or layered clothing

Repeatedly eating large amounts of

sweet or high-fat foods

Use of syrup of ipecac, laxatives,

weight loss drug orlistat, or OTC drugs
that can cause fluid loss, menstrual
symptoms relief meds

Use of dietary supplements or herbal

products for weight loss

Food hoarding

Leaving during meals to go to use toilet

Eating in secret

Frequent checking in the mirror for

perceived flaws

Causes of Eating Disorders

Biology
People with first degree relatives
sibling or parents with eating
disorders maybe more likely to develop
eating disorders
Serotonin a naturally occurring brain
chemical, may influence eating
behaviors

Psychological and Emotional health

Low self-esteem, perfectionism,
impulsive behavior and troubled
relationships

Society
Modern Western Culture Environment
cultivates and reinforces desire for
thinness
Success and worth = being thin
Peer Pressure
Risk Factors

Being Female

Age

Family History

Emotional disorders

Dieting

Transitions

Sports, Work and Artistic activities

Complications

Death

Health Problems

Multiple Organ Failure

Depression

Suicidal thoughts or behavior

Absence of menstruation (amenorrhea)

Bone loss

Stunted growth

Digestive problem

Kidney damage

Severe tooth decay

High or low blood pressure

ANOREXIA NERVOSA
Criteria for Anorexia nervosa
1. Restriction of food intake leading weight
loss or failure to gain weight
2. Fear of becoming or gaining weight

3.

Distorted view of themselves and of their

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

Types of Anorexia

Restricting type: stereotype of

anorexia nervosa. The person does not
regularly engage in binge eating.

Binge eating/Purging type: The

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

Refusal to eat and denial of hunger

Intense fear of gaining weight

A negative or distorted self-image

Excessive exercise

Flat mood or lack of emotion

Irritability

Fear of eating in public

Preoccupation with food

Social withdrawal

Trouble sleeping

Thin appearance
Physical Examination of Anorexia

Soft downy hair present in the body

(lanugo)

Menstrual irregularities or loss of

menstruation (amenorrhea)

Constipation

Abdominal pain

Dry skin

Frequently being cold

Irregular heart rhythms

Low blood pressure

Dehydration

BULIMIA NERVOSA
Episodes of binging and purging
A person typically eat a large amount of
food in short period of time
Try to rid himself of extra calories thru
vomiting or excessive exercise

Normal weight or even slight overweight

Manifestations of Bulimia

Eating until the point of pain or

discomfort , often with high-fat or
sweet foods

Self-induced vomiting

Laxative use

Excessive exercise

Unhealthy focus on body shape and

weight

Distorted, excessively negative body

image

Low self-esteem

Going to the bathroom after eating or

during meals

Feeling that you cant control your

eating behavior

Abnormal bowel functioning

Physical Examination of Bulimia

Damaged teeth and gums

Swollen salivary glands in cheeks

Sores in throat and mouth

Dehydration

Irregular heartbeat

Sores, scars or calluses in hands or

knuckles

Menstrual irregularities or loss of

menstruation (amenorrhea)

Constant dieting or fasting

Possibly drug or alcohol abuse

BINGE-EATING DISORDER
Person regularly eats excessive amounts
of food (binge) but dont compensate
with exercise or purging
Eat when he/she is not hungry and
continue eating even long after he/she is
uncomfortably full
After a binge, may feel guilty or
ashamed, which can trigger new round of
binging
Normal in weight , overweight or obese
Symptoms may include:

Eating
To the point of discomfort or pain
Much more food during binge episode
than during normal snack or meal

Faster during binge episodes

Feeling that youre eating behavior is out
of control
Frequently eating alone
Feeling depressed, disgusted or guilty
over amount eaten

WEIGHT GAIN
They are sick that surfeit with too much
As they that starve with nothing.

Shakespeare, Merchant of Venice

OBESITY
a metabolic disorder resulting from
imbalance between energy uptake and
expenditure
Chronic - lifelong treatment required
Treatment controls do not cure disease
No short term solutions

- Disease recurs after treatment is

withdrawn

HPI: Weight Gain

Total weight gain: time period, sudden or

gradual, desired or undesired, possibility
of pregnancy

Change in lifestyle: social changes,

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

Medications: steroids, oral

contraceptives, insulin antidepressants

Measures of Obesity
1. Ideal Body Weight (Filipinos)
Male = 112lbs for first 5ft of height +
4 (x each inch above 5)
Female = 106lbs for first 5ft of height
+ 4 (x each inch above 5)
2. Height
3. Weight Circumference
Measured midway between lower
border of costal margin and iliac crest
South Asians
o Male = >90cm
o Female = >80cm
**Central obesity = apple more insulin
resistant
**Hip obesity = pear less insulin resistant
Energy Density of Food
Standard food portions have increased
over the last 20 yrs.

Obesity in the Philippines

1 out 5 people are overweight
According to National Statistics
Coordination Board, 26.6% of Filipinos
are overweight, higher than 16.6% of
1993
5.2% of Filipinos are obese, that means 5
million Filipinos whose health are
compromised
There are 2x more obese females than
males in Philippines
Contributors to Weight

Genetics
Body weight is 4-070% heritable

Environment
In utero
Food availability /consumption
Physical activity
Obesity-related Comorbidities

Respiratory: Obstructive sleep apnea,

Bronchial asthma, Pickwickian syndrome
(obesity hypoventilation syndrome)

Malignant: endometrial, prostate, colon,

breast, gallbladder and possibly lung
cancer

Psychological: Social stigma and

depression
Cardiovascular: CAD, hypertension, LVH,
cor pulmonale, cardiomyopathy,
atherosclerosis, pulmonary HPN
CNS: stroke, idiopathic intracranial
hypertension, neuralgia paresthetica
Obstetric and perinatal: pregnancyrelated HPN, fetal macrosomia, pelvic
dystocia
Surgical: Increased surgical risks and
post-op complaints, including wound
infection, post-op pneumonia, DVT and
pulmonary embolism
Pelvic: Stress incontinence
Gastrointestinal: Cholecystitis,
Cholelithiasis, Non-alcoholic
steatohepatitis (NASH), fatty liver
infiltration, reflux esophagitis
Orthopedic: osteoarthritis, coxa vera,
slipped capital femoral epiphysises,
chronic lumbago
Metabolic : Type 2 DM, prediabetes,
metabolic syndrome, dyslipidemia
Reproductive (in women): anovulation,
early puberty, infertility,
hyperandrogenism, polycystic ovaries
Reproductive (in men): Hypogonadotropic
hypogonadism
Extremity: Venous varicosities, lower
extremity venous and/or lymphatic
edema

Physical Examination

Cutaneous: intertriginous rashes from

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

Cardiac and respiratory: cardiomegaly

and respiratory insufficiency

Abdominal: tender hepatomegaly due to

hepatic fatty infiltration or NASH and
striae

Extremities : joint deformities (eg. coxa

vera), osteoarthritis, pressure ulcers,
generalized and lipodystrophic fat
distribution

Miscellaneous: reduced mobility and

difficulty maintaining hygiene
Obesity Differential Diagnosis

Type 2 DM

Fatty Liver
GERD
Hirsutism
Polygenic hypercholesterolemia
Hypothyroidism
Acromegaly
Insulinoma
Kallman syndrome and idiopathic
hypogonadotropic hypogonadism
Generalized Lipodystrophy
Polycystic ovaries (Stein-Leventhal
syndrome)
Cushings syndrome
Adiposa dolorosa (Dercum disease)
Partial lipodystrophy assoc. with localized
lipohypertrophy

DIAGNOSIS
Laboratory Studies

Fasting Lipid panel

Liver function test

Thyroid function test

Fasting glucose and hemoglobin A1c

(HbA1c)
Evaluation of Degree of Body fat

BMI calculation, waist circumference,

waist-hip ratio

Caliper-derived measurements of skinfold

thickness

Dual energy radiographic absorptiometry

(DEXA)

Bioelectrical impedance analysis

Ultrasonography to determine fat

thickness

Underwater weighing
APPROACHES TO OBESITY MANAGEMENT
Prevention of further weight gain

Behavioral Modification

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

1 Serving equals:
Carbohydrates = 15 g
Meat = 1 ounce
Fat = 1 teaspoon (5g)
Exercise
Minimize offending drugs
Weight loss medication
Bariatric surgical interventions