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Chapter 9 – Weight Management: Overweight, Obesity, and Underweight
Learning Objectives
After completing Chapter 9, the student will be able to:
1. Define overweight and obesity using the body mass index.
2. Explain fat cell development and its role in obesity.
3. Discuss the role of lipoprotein lipase in obesity.
4. Discuss the set point theory of obesity.
5. Discuss the role of genetics, leptin, and ghrelin in the development of obesity.
Assignments and Other Instructional Materials
The following ready-to-use assignments are available in this chapter of the instructor’s manual:
• New! Case study
• Worksheet 9-1: Weight Management Medications1
• Worksheet 9-2: Clinical Application—Bariatric Surgery
Other instructional materials in this chapter of the instructor’s manual include:
• Answer key for How To (p. 288) activity
• Classroom activities
• Worksheet answer keys (as appropriate)
Lecture Presentation Outline4
“Of special interest to...” symbol key: = Hot Topic = Personal Health
= Health Care Professionals = Science Majors
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Key to instructor resource annotations (shown to the right of or below outline topics):
PL = Available on Power Lecture DVD-ROM (ISBN 0538797592): V = video
TRA = Transparency acetates: 12e TRA = 12th edition, 11e TRA = 11th edition, 10e TRA = 10th edition
Website = Available for download from book companion website: HN = student handout
IM = Included in this instructor’s manual: WS = worksheet, CA = classroom activity, CI = Canadian
information
Introductory/whole chapter resources: PL figure JPEGs; Test Bank; IM WS 9-7, CA 9-1, 9-2
I. Overweight and Obesity 12e TRA 17; IM CI 9.2, 9.3
Overweight (BMI 25-29.9) and obesity (BMI ≥ 30) are widespread health problems that are continuing to
increase. Many refer to overweight and obesity as an epidemic. For good health, weight management is
important.
A. Fat Cell Development 10e TRA 98
1. Fat cell numbers
a. Fat cell numbers increase most rapidly in later childhood and early puberty.
2. Fat cell size
3. The adverse effects of fat in nonadipose tissue are called lipotoxicity.
B. Fat Cell Metabolism
1. Lipoprotein lipase promotes fat storage.
C. Set-Point Theory
1. The body’s natural regulatory centers maintain homeostasis at a set point.
2. The human body tends to maintain a certain weight.
II. Causes of Overweight and Obesity
A. Genetics and Epigenetics PL V “Anti-Hunger Hormone”
2. Leptin (also called the ob protein) 10e TRA 99
a. Protein that acts as a hormone to increase energy expenditure and decrease appetite.
3. Adiponectin
4. Ghrelin
a. Protein that acts as a hormone to stimulate the appetite and promote energy storage.
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b. Secreted by stomach cells.
5. PYY
6. Uncoupling Proteins
a. Influence energy metabolism.
B. Environment – The gene pool of our population remains relatively unchanged.
1. Overeating PL V “Calorie Counts on Restaurant Menus,” “Economic Hardship & Obesity”
2. Physical Inactivity
a. Modern technology replaced the need for many physical activities.
b. Physical activity is important to allow people to eat enough food to get needed nutrients.
III. Problems with Overweight and Obesity PL V “Dangers of Central Obesity”
Obesity problems depend on many factors such as the extent of overweight, age, health status, and genetic
makeup. Risk factors may differ among individuals.
A. Health risks are evaluated using BMI, waist circumference and disease profiles.
1. Overweight people who are in good health may not need to lose weight.
2. Obese or overweight people with risk factors could improve health by losing weight or using other diet
and exercise strategies. Risk factors include:
a. Hypertension
b. Cigarette smoking
3. Obese or overweight people with the following life-threatening-conditions may improve health by
losing weight:
a. Heart disease
B. Perceptions and Prejudices IM CA 9-3
1. Social Consequences
2. Psychological Problems 10e TRA 100
a. Feelings of rejection, shame, and depression are common.
b. Ineffective treatments can lead to a sense of failure.
C. Dangerous Interventions
1. Fad Diets
2. Weight-Loss Products IM CI 9.5
a. Ephedrine-containing products inhibit serotonin and suppress the appetite. Supplements
3. Other Gimmicks
a. Hot baths, steam, and saunas have no impact on fat loss.
IV. Aggressive Treatments for Obesity
Individuals with clinically severe obesity and major medical problems may benefit from drugs or bariatric
surgery. But changing and improving eating and exercise habits offer the greatest benefit.
A. Drugs IM WS 9-1, CA 9-4
1. Sibutramine suppresses the appetite and is most effective when used with a reduced-kcalorie diet and
increased physical activity. There are many side effects.
2. Orlistat blocks fat digestion and absorption. There are many side effects.
B. Surgery 11e TRA 22; IM WS 9-2, CA 9-5
1. Surgery is an option for those who have tried weight-loss programs and failed, have a BMI ≥ 35, and
are having health problems due to their weight.
V. Weight-Loss Strategies 10e TRA 102; IM WS 9-3, 9-8, CA 9-9, CI 9.1, 9.4
A life-long eating plan for good health, which includes nutritionally adequate eating, reasonable expectations,
regular physical activity, and permanent lifestyle changes, is best for achieving permanent weight loss. Weight
loss of 1-2 pounds per week or 10% of body weight in six months is safe.
A. Eating Plans
PL V “Diet Comparison: Low-Carb vs. Low-Fat vs. Mediterranean,” “Fast-Food Breakfast Choices,” “Diet
Soda & Weight Gain,” “Amazing Weight Loss: 200 Pounds,” “Seven Styles of Eating: Diet Strategy,”
“Choosing Nutrient-Dense Snacks”; Web HN 9-1; IM CA 9-8, CI 9.6
1. Be Realistic about Energy Intake
a. 300-500 kcalories/day reduction for BMI between 27 and 35.
b. 500-1000 kcalories/day reduction for BMI 35.
c. Dietary Guidelines should be followed.
2. Diet should be nutritionally adequate while avoiding excessive consumption.
B. Physical Activity 11e TRA 23; IM CI 9.7
1. An individual’s body weight as well as intensity and duration of activity influence energy expenditure.
2. Physical activity increases the amount of discretionary kcalories that can be consumed.
3. Metabolic rates can rise with daily vigorous activity.
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8. Spot Reducing
a. Regular aerobic exercise and weight loss will help trouble spots.
C. Environmental Influences
1. Lighting, décor, aromas, and sounds can influence intake.
2. Accessibility, ease, and convenience of food influences how much is consumed.
3. Social events and interactions can lead to increased intake.
D. Behavior and Attitude Website HN 9-2; IM WS 9-4, 9-5, 9-6, CA 9-6, 9-7
1. Behavior modification requires time and effort.
2. Awareness of behavior is the first key.
3. Changing behaviors one at a time works best.
5. Personal attitudes toward food and eating must be understood.
6. Support groups may be helpful for some people.
E. Weight Maintenance
1. Successful weight-loss maintenance programs use different criteria so they are difficult to compare.
3. Frequent self-monitoring is recommended.
F. Prevention
1. Eat regular meals and limit snacking.
G. Public health programs have been suggested to: PL V “Fighting Obesity in the Community”; IM CI 9.8
1. Develop safety standards for foods.
VI. Underweight (BMI 18.5)
Incidences of underweight and associated health problems are less prevalent than overweight and obesity
problems.
A. Problems of Underweight
1. Causes are diverse.
B. Weight-Gain Strategies
1. Energy-dense foods can be included but choose fats wisely to avoid the associated cardiac risks.
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6. Exercising to build muscles will support increases in muscle mass.
VII. The Latest and Greatest Weight-Loss Diet—Again IM CA 9-10, CI Highlight
A. Fad Diet’s Appeal – Fad diets involve misconceptions and distortions of facts.
1. Don’t Count kCalories
a. Fad diets often require strict elimination of certain foods, leading to low kcalorie intake.
Case Study5
Sally is a 43-year-old mother of two who has gained 50 pounds since the birth of her youngest child five years ago.
She is 64 inches tall and weighs 180 pounds with a BMI of 30.8. Her waist circumference is 37 inches. She
describes herself as a “food addict” and explains how recent stresses in her life have resulted in her turning to food
for comfort. Although she eats very little during the day when she is busy, she describes cravings for sweets that
come on late at night. Her father recently died from complications of type 2 diabetes and Sally is very motivated to
“not get diabetes, too.” Although a recent physical exam by her doctor revealed mildly elevated blood pressure, all
her laboratory blood tests were normal, including blood glucose and cholesterol. Sally has recently joined a 12-step
support program for people with food addictions and states that this helps keep her focused on healthy habits. She
loves to cook for her family, none of whom are overweight. She has also joined a health club in a renewed effort to
lose weight and get back in shape.
1. Based on her health history and physical measurements, describe how you would determine the seriousness of
Sally’s weight in relation to her health.
2. Using information in this chapter, what would you estimate to be a reasonable amount of weight for Sally to
lose over the next six months?
3. What meal planning strategies could help prevent Sally’s nighttime food cravings?
4. Sally has determined that—to lose weight—she needs to limit her daily caloric intake to 1400 kcalories. Use
Table 9-5 to plan one day of meals and snacks to meet her nutritional needs within this calorie level.
5. What are some advantages for Sally of keeping a food and exercise record? What other habits besides food
intake and physical activity may be especially useful for Sally to record?
6. Why might strength training be an important addition to Sally’s exercise regimen?
Answer Key:
1. BMI indicates obesity; waist circumference is high, indicating high risk for health-related diseases as result of
her weight; family history of diabetes; personal history of high blood pressure. Aggressive treatment for weight
loss is indicated.
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Suggested Classroom Activities
This chapter provides an opportunity to relax, let students share experiences about eating habits and weight control,
and address plans for weight gain or loss. The end of Chapter 9 is a good place to actively plan diets.
Classroom Activity 9-2: Debates6
Key concept: Instructor’s choice Class size: Small to medium
Instructions: Have students research and debate a controversial topic such as causes of obesity or weight-loss
strategies including dangerous interventions, aggressive treatments, and eating plans. Greater interest in such topics
is often generated by debates than by straight lectures.
Classroom Activity 9-3: Evaluating the Impact of the Media on Body Image7
Key concept: Media’s influence on body image Class size: Any
Classroom Activity 9-4: Weight Management Medications
Key concept: Use of medications for weight loss/gain Class size: Any
Materials needed: Copy of Worksheet 9-1 for each student
Instructions: Distribute Worksheet 9-1. For each of the medications listed, instruct students to look up both the
clinical indications and the monitoring aspects associated with a client taking this drug for weight management
issues.
Classroom Activity 9-5: Clinical Application of Bariatric Surgery
Key concept: Bariatric surgery Class size: Any
Materials needed: Copy of Worksheet 9-2 for each student
Instructions: Distribute Worksheet 9-2. Instruct students to think about the surgical procedure of bariatric surgery
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Classroom Activity 9-6: Eating Attitudes Test
Key concept: Eating behaviors/attitudes Class size: Any
Classroom Activity 9-7: Food Diary and Examination of Eating Habits
Key concept: Eating habits/behaviors Class size: Any
Classroom Activity 9-8: Computer Diet Analysis8
Key concept: Analysis of dietary intake Class size: Any
Materials needed: Computer terminals with diet analysis software
Instructions: The use of a computer program for diet analysis can help students analyze their diet intakes. Some
instructors report that this activity helps facilitate eating behavior changes that result in weight loss or weight gains.
Classroom Activity 9-9: Evaluation of a Weight-Loss Program
Key concept: Evaluating weight-loss programs Class size: Any
Classroom Activity 9-10: Profiling Weight-Loss Scams9
Key concept: Evaluating weight-loss programs/products Class size: Small to medium
How To “Try It” Activities Answer Key
How to Compare Foods Based on Energy Density
The egg has an energy density of 1.56 kcal per gram, and the tuna has an energy density of 1.16 kcal per gram,
making the egg 35% more energy dense.
Critical Thinking Questions10
These questions will also be posted to the book’s website so that students can complete them online and e-mail their
answers to you.
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1. Briefly describe how each of the following may be a factor related to an individual’s obesity dilemma:
a.) gender (such as being female) and ethnicity (African Americans and Hispanics); b.) lipoprotein lipase;
c.) set-point theory; d.) leptin; and e.) adiponectin.
Answer: a.) As noted in your text, women tend to lay down fatty deposits in different areas than men. Women
will accrue more fat in their hips and thighs, while men will accrue more fat in their stomachs. Women also
retain a higher fat mass than do men, presumably for pregnancy and lactation. Therefore, there are some
physiologic factors that complicate the weight-loss equation for a female.
2. What are the differences between ghrelin and PYY?
Answer: Ghrelin is a protein that works as a hormone in the hypothalamus. It is secreted in the stomach and
3. What recommendations would you make to an individual that is having problems gaining weight?
Answer: It is not always necessary to have an underweight individual gain weight. Many times, the individual
will gain weight as they grow older without any effort. Therefore, it is important to start with an assessment of
the individual to ascertain if there are any health risks prior to making any recommendations.
4. There are many marketed remedies for weight loss. Distinguish between those that have some proven scientific
efficacy and those that do not. How would you help a client to select the safest approach to weight loss when
many clients become so desperate for a quick fix?
Answer: It can be difficult for the RD to keep up with all the diet fads that come onto the market. Not only are
there dietary plans but there are supplements, exercise programs, and psychological programs that are all sold to
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pressure and heart rate. While it appears to be a powerful appetite suppressant, there are many potential side
effects for an individual that is severely obese. Strict medical supervision is required when taking this drug.
Orlistat (Xenical or alli): This medication controls weight by inhibiting the absorption of fat in the GI tract. It is
available over the counter and can be a very effective form of weight control in the form of negative feedback.
Individuals taking orlistat quickly learn that when they consume a diet that is high in fat, they will require close
access to a toilet because the drug helps to excrete approximately 30% of the fat in the diet, thus reducing the
energy-yielding nutrients absorbed. The result is loose, runny stools that are unpleasant, which serves as a
negative feedback mechanism for the client taking the drug. Many clients have been very successful on a
program of orlistat with diet and exercise, for which the company has hired RDs to educate and instruct
individuals. Given the negative feedback loop with the drug, individuals may not be automatically attracted.
However, issues of hydration and fat-soluble vitamin supplementation can be problematic for those individuals
that do not seek counseling. Because orlistat blocks over 30% of fat absorption, vitamins that are fat soluble can
be compromised in their absorption. This can be problematic for those individuals that are already on a dietary
plan that is insufficient in nutrients. Therefore, individuals pursuing this option should be closely supervised to
ensure optimal health and nutrition.
5. Your text discusses four areas that are all important to an optimal weight-loss program. Discuss each area and
how you might approach these important strategies to optimize the client’s weight loss maintenance.
Answer: The areas that the text mentioned were eating plans, physical activity, environmental influences, and
behavior and attitude.
Eating Plans: It is always important to select an eating program that will provide a balanced diet (one that does
not make the individual feel that they are being deprived) and allows for a moderate weight loss. Weight losses
Physical Activity: We have discussed many times the importance of physical activity. For the individual that is
overweight or obese, activity can be difficult or embarrassing. Encouraging physical activities such as walking,
walking the stairs or to the car, etc. is very important. Increasing that activity as weight is lost improves
confidence for the individual and increases calorie needs. The individual can also join a gym or class with
members that are of like weight so that they can talk about their goals. Socializing in this manner is important.
What is most important is moving in any number of ways. The RD that develops a system to reward movement
while on a weight-loss program for clients will win in more ways than one.
IM Worksheet Answer Key
Worksheet 9-1: Weight Management Medications11
Medication
Classification
Clinical Indication
Monitoring Aspects
Megestrol
acetate
(Megace)
Orexigenic
agent
Treatment of metastatic breast
cancer, metastatic endometrial
cancer; stimulation of appetite and
promotion of weight gain in patients
Monitor for side effects: increased
appetite and weight gain, swelling,
hyperglycemia, headache, breast
tenderness, impotence, decreased
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Medication
Classification
Clinical Indication
Monitoring Aspects
Sibutramine
hydrochloride
monohydrate
(Meridia)
Norepinephrine,
serotonin and
dopamine
inhibitor
Weight loss/maintenance in
overweight patients
Monitor for side effects: elevated
blood pressure or heart rate, allergic
reactions, dizziness, drowsiness
Orlistat
(Xenical, alli)
Lipase inhibitor
Weight loss/maintenance in
overweight patients
Monitor for improvement of blood
glucose in diabetic patients; monitor
for compliance with fat-restricted diet
and daily multivitamin supplement;
monitor liver function
1. FDA (Food and Drug Administration)
2. Yes
3. See “Monitoring Aspects” column of table.
Worksheet 9-2: Clinical Application—Bariatric Surgery12
1. Answers will vary.
2. A gastric bypass is a surgical procedure in which a route for food which bypasses the stomach, duodenum, and
part of the jejunum is created. The surgeon staples off most of the stomach to create a small pouch, and then
attaches this pouch directly to the small intestine. This results in both a restriction of the quantity of food that
can be eaten at one time and a reduction in the amount of energy-yielding and other nutrients absorbed from the
food.
3. Criteria include either (a) BMI of 40 or more (100 pounds overweight for men, or 80 pounds for women) or (b)
BMI of 35-39.9 and 1 or more serious comorbidities, plus an understanding of and willingness to comply with
the required lifestyle changes post-surgery.
4. $20,000 to $25,000
Worksheets 9-3, 9-4, 9-5, and 9-6 – Answers will vary.
Worksheet 9-7: Chapter 9 Crossword Puzzle
