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Chapter 9 – Weight Management: Overweight, Obesity, and Underweight
Learning Objectives
After completing Chapter 9, the student will be able to:
9.1 Describe how body fat develops and why it can be difficult to maintain weight gains and losses.
a. Define overweight and obesity using the body mass index.
9.2 Review some of the causes of obesity.
a. Discuss the role of genetics, leptin, and ghrelin in the development of obesity.
b. Identify environmental causes of obesity.
9.4 Explain the risks and benefits, if any, of several aggressive ways to treat obesity.
9.5 Outline reasonable strategies for achieving and maintaining a healthy body weight.
9.6 Summarize strategies for gaining weight.
9.7 Contrast the differences between popular fad diets and weight-loss diets based on sound nutrition.
Assignments and Other Instructional Materials
The following ready-to–use assignments are available in this chapter of the instructor’s manual:
• New! Case Study 9-1: Low-Energy-Density Dinner
• Case Study 9-2: Lifestyle Changes for Weight Loss
• Worksheet 9-1: Weight Management Medications1
Other instructional materials in this chapter of the instructor’s manual include:
• Answer key for How To (pp. 276, 295) activities
• Classroom activities, featuring New! snack comparison activity (9–3)
• Worksheet answer keys (as appropriate)
• New! Handout 9-1: Proteins Involved in Regulation of Food Intake and Energy Homeostasis
• New! Handout 9-2: Weight-Loss Consumer Bill of Rights (An Example)
• New! Handout 9-3: Selected Herbal and Other Dietary Supplements Marketed for Weight Loss
• New! Handout 9-4: Recommendations for a Weight-Loss Diet
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Visit the book’s instructor companion website to download:
• Handout 9-7: Very-Low-kCalorie Diets
• Handout 9-8: How to Change Behaviors to Support Weight Loss
Lecture Presentation Outline4
Key to instructor resource annotations (shown to the right of or below outline topics):
TRA = Transparency acetates: 13e = 13th edition, 12e = 12th edition, 11e = 11th edition, 10e = 10th edition
I. Overweight and Obesity (Figure 9-1) 12e TRA 17
A. Fat Cell Development – Explain how fat cells develop, including: 10e TRA 98
1. Fat cell numbers (Figure 9-2)
a. Hyperplastic obesity
b. Apoptosis
II. Causes of Overweight and Obesity
A. Genetics and Epigenetics IM HN 9-1
1. Explain and discuss epigenetics
2. Leptin – Define and explain leptin (Figure 9-3) 10e TRA 99
B. Environment – Explain the environmental influence over obesity, including:
1. Overeating
2. Physical Inactivity
III. Problems of Overweight and Obesity
A. Health Risks – Discuss health risks associated with overweight and obesity
1. Overweight in Good Health – Overweight people who are in good health may not need to lose weight
2. Obese or Overweight with Risk Factors – Obese or overweight people with risk factors could improve
health by losing weight; risk factors include:
a. Hypertension
3. Obese or Overweight with Life-Threatening Condition – Obese or overweight people with the
following life-threatening-conditions may improve health by losing weight:
a. Heart disease
b. Type 2 diabetes
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c. Sleep apnea
B. Perceptions and Prejudices IM CA 9-2
1. Social Consequences
a. Prejudices and discrimination
C. Dangerous Interventions IM HN 9-2, 9-3
1. Fad Diets
2. Weight-Loss Products
a. Ephedrine-containing products
IV. Aggressive Treatments for Obesity
A. Drugs IM WS 9-1
1. Orlistat
2. Phentermine, diethylpropion, and phendimetrazine
V. Weight-Loss Strategies IM CS 9-1, 9-2, WS 9-3, HN 9-4
A. Set Reasonable Goals 10e TRA 102
1. Small changes
B. Eating Patterns – Explain the following: Website HN 9-7
1. Be Realistic about Energy Intake (Figure 9-6)
a. 300-500 kcalories/day reduction for BMI between 27 and 35
b. 500-1000 kcalories/day reduction for BMI 35
2. Emphasize Nutritional Adequacy
3. Eat Small Portions
B. Physical Activity – Discuss the following: 11e TRA 23
1. Activity and Energy Expenditure
2. Activity and Discretionary kCalories (Figure 9–8)
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c. Daily routines
8. Spot Reducing
a. Regular aerobic exercise
b. Strength training
c. Stretching
C. Environmental Influences – Explain how the following influence activity:
1. Atmosphere
2. Accessibility
D. Behavior and Attitude Website HN 9-8; IM WS 9-4, 9-5, 9-6, CA 9-4
1. Behavior modification
2. Become Aware of Behaviors (Figure 9-9)
E. Weight Maintenance
1. Successful weight-loss maintenance
2. Vigorous exercise and careful eating plans
3. Frequent self-monitoring
F. Prevention
1. Eat regular meals and limit snacking
G. Community Programs (Table 9–4)
VI. Underweight (BMI 18.5)
A. Problems of Underweight – Discuss the problems associated with being underweight
B. Weight-Gain Strategies
1. Energy-Dense Foods
VII. Highlight: The Latest and Greatest Weight-Loss Diet—Again IM CA 9-5, 9-6, WS 9–7, HN 9-5, 9-6
A. Fad Diets’ Appeal – Fad diets involve misconceptions and distortions of facts
1. Don’t Count kCalories – Fad diets often require strict elimination of certain foods
2. Follow a Plan
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Case Studies5
Case Study 9-1: Low-Energy-Density Dinner
Christine C. is 49-year-old nurse who works full-time at a senior health care center. She is 65 inches tall and her
usual weight is 150 pounds. Over the past year, Christine has gained 12 pounds although she is not aware of any
major changes in her eating or exercise habits. She has set a goal to eat three balanced meals a day with no more
than 500 calories per meal. Christine is tired and hungry from a long day at work. She is trying to decide between
the following items for a quick and easy dinner:
Canned beef chili with beans: 1 cup (247 grams), 305 kcalories, 11 grams fat, 6 grams dietary fiber, and 18 grams
protein.
Canned lentil vegetable soup: 1 cup (205 grams), 130 kcalories, 3 grams fat, 5 grams dietary fiber, and 6 grams
protein.
Cornbread: 1 piece (78 grams), 290 kcalories, 13 grams fat, 1 gram dietary fiber, 3 grams protein.
Sprouted whole-wheat bread: 2 slices (45 grams), 100 kcalories, 2 grams fat, 5 grams dietary fiber, 6 grams protein.
1. Use the formula discussed in this chapter to calculate the energy density of the four foods Christine is
considering for dinner.
2. Based on these calculations, which two foods provide the fewest calories “per bite”? Which two provide the
most calories “per bite”?
3. How might Christine use this information about energy density to help her select a satisfying meal within her
calorie goal?
4. What are some reasonable meals that Christine could prepare from these foods that would help her stay within
her kcalorie goal? (Use at least 2 of the 4 foods listed.)
5. What other foods might Christine consider adding to these convenience foods to create a more balanced meal
that remains low in energy density?
6. How might Christine use the serving size information on the Nutrition Facts label to help her with meal
planning?
Answer Key
1. Canned beef chili with beans: 305 kcalories/247 grams= 1.23; lentil vegetable soup: 130 kcal/205 grams = 0.63;
cornbread: 290 kcal/78 grams = 3.7; sprouted wheat bread: 100 kcal/45 grams = 2.2
Case Study 9-2: Lifestyle Changes for Weight Loss
Sally is a 43-year-old mother of two who has gained 50 pounds over the past five years. She is 64 inches tall and
weighs 180 pounds with a BMI of 30.8. Her waist circumference is 37 inches. She acknowledges that she is not as
physically active as she would like to be. She also notes how recent stresses in her life have affected her sleep and
seem to have triggered her appetite for sweets. Sally’s father recently died from complications of type 2 diabetes and
her mother and sisters are overweight. Sally says she is very motivated to “not get diabetes” and is disturbed that her
recent physical exam revealed mildly elevated blood pressure, glucose, and cholesterol levels.
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1. How does Sally’s family history influence her weight and risk for diabetes? What lifestyle choices may
influence her genetic predisposition to be overweight?
2. Using information in this chapter, what is a reasonable goal weight for Sally? How long would you estimate it
would take her to safely lose this amount of weight?
3. What weight-loss strategies may help curb Sally’s stress-related eating?
4. Sally has determined that—to lose weight—she needs to limit her daily caloric intake to 1400 kcalories. Use
Table 9-2 and show a one-day plan for meals and snacks that meet her nutritional needs within this calorie level.
5. What are some advantages to Sally keeping a food and exercise record? What other factors besides food intake
and physical activity may be useful for Sally to record?
6. Why might strength training be an important addition to Sally’s exercise regimen?
Answer Key
1. Refer to the information on genetics and epigenics in section 9.2. Important points from text: you cannot change
the genome you inherit, but you can influence the epigenome. Physical activity can minimize the genetic influences
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 completion of Chapter 9 is a good point at which to actively plan
diets.
Classroom Activity 9-2: Evaluating the Impact of the Media on Body Image7
Key concept: Media’s influence on body image Class size: Any
Instructions: Before class, have students bring photos of models that appear in fashion magazines that they
commonly read. Some examples of magazines include Seventeen, Self, Shape, and Redbook. For men, magazines
pertaining to body building can be examined.
Present information about the eating disorders anorexia nervosa and bulimia nervosa. Discuss how society
influences body image and fosters, through advertising, an unhealthy desire to be overly thin.
Have students analyze magazines and look for anorexic appearances that contribute to pressures to be overly thin.
Discuss the implications and the prevalence of eating disorders in our society. Discuss other ways that students
internalize pressure to have perfect bodies. Next, have students present ways that these pressures affect self-concept
and how students can achieve a realistic body image.
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Classroom Activity 9-3: Snacking with a Purpose (Snack Comparison)8
Key concepts: Energy density; meal planning for weight loss/gain Class size: Any
Instructions: Read the case scenario to students, present the high-calorie and low-calorie snack examples to them,
and then use the discussion questions to guide them in considering how the energy density of food choices can be
manipulated to promote weight gain or weight loss/maintenance.
Case scenario: You are a registered dietitian in an outpatient clinic. A mother brings her two young daughters in to
see you. One daughter is underweight and needs suggestions for high-calorie snacks to promote weight gain. The
other daughter is at a normal weight and struggles with wanting to eat snacks each time her sister does. The family is
asking for help with balancing low-calorie snack ideas with high-calorie snack ideas, using basically the same
groceries.
Discussion questions:
1. What additional suggestions do you have for snack ideas that use similar foods and can be modified to be higher
or lower in calories?
2. What types of beverages should be recommended to help with weight gain? And to prevent weight gain?
3. What other suggestions do you have for promoting well-balanced nutrition for each child while achieving their
weight goals?
Answer key:
1. Answers will vary.
8 Contributed by Carrie King
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Classroom Activity 9-4: Food Diary and Examination of Eating Habits
Key concept: Eating habits/behaviors Class size: Any
Materials needed: Copy of standard food record form + copy of Worksheet 9-5 for each student
Instructions: Provide a food diary form for students to fill out. Have them calculate their kcalorie intakes for the day.
To examine eating patterns and habits, have students complete Worksheet 9-5: Exploring Eating Habits. This
worksheet examines when, where, and why foods are generally eaten. After students have completed these sections,
instruct them to write changes they want to make in their food behavior patterns. Discuss the major changes that
students want to make and encourage a discussion to provide suggestions for making changes.
Classroom Activity 9-6: Profiling Weight-Loss Scams9
Key concept: Evaluating weight-loss programs/products Class size: Small to medium
Instructions: For this highlight activity, have students search your local area drug stores, book stores and markets for
the latest and greatest weight-loss products (scams). Such products might include diet pills, programs, books, or
magazine articles. Ask the students to select three programs (preferably a variety of the three, e.g. a book, a diet pill,
and a magazine program). Each student should outline the points promoted for the diet program product, the strong
points for the product, and the weak points. Then, following the guidelines on Handout 9-6, ask the students to write
a paper that outlines why each dietary product is either a fad diet or weight-loss scam or when appropriate, follows
the “Healthy Diet Guidelines” (10 points per area). Depending on your time in class and the size of the class, it can
be fun and informative for the students to share their findings. Design the assignment in a manner that students will
select a variety of products, books, etc., minimizing the overlap of the same products.
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.
How to Identify a Fad Diet or Weight-Loss Scam
The student will need to locate an advertisement for a weight-loss plan to critique, state whether or not he/she
perceives it as a fad diet, and then explain the basis for this judgment. A claim that the plan is a fad diet should be
supported by examples of how the plan resembles the one described in the How to box. If the plan is ruled not to be
a fad diet, the student should point out how it follows the healthy weight–loss guidelines in the chapter.
Study Card 9 Answer Key
1. a
2. Lipoprotein lipase (LPL) is an enzyme that hydrolyzes triglycerides passing by in the bloodstream and directs
their parts into both adipose and muscle cells, where they can be metabolized or reassembled for storage. This
7. People who combine diet and exercise typically lose more fat, retain more muscle, and regain less weight than
those who only follow a weight-loss diet. Those who exercise reap important health benefits—reduced
abdominal obesity and improved blood pressure, insulin resistance, and cardiorespiratory fitness—regardless of
8. Keeping a record will help to identify eating and exercise behaviors that may need changing, raise awareness of
them, and establishes a baseline against which to measure future progress. Behavior modification strategies
focus on learning desired eating and activity behaviors and eliminating unwanted behaviors. The individual can
start with small time-specific goals for each behavior and then practice these desired behaviors until they
Critical Thinking Questions10
1. How can you modify an obseogenic environment?
2. How does the presence of risk factors potentiate the development of chronic disease for the overweight
individual?
3. Describe diet planning methods that would help to increase weight loss for overweight and obese individuals.
4. Many individuals hope to lose weight in certain areas, a concept commonly known as “spot reducing.” Based
on your understanding of metabolism, is this a realistic goal?
5. Why are weight-loss accomplishments hard to define for the average individual?
6. How does being underweight affect health? What factors would contribute to an individual becoming
underweight?
Answer Key
1. An obesogenic environment represents the direct/indirect influences that affect an individual’s daily struggle
with issues that “lead us to fatness.” When considering methods that would possibly modify this type of
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divert time from sedentary pursuits (and the mindless eating that often accompanies them).
2. Individuals who are overweight are already at risk for health problems. The presence of additional risk factors
such as smoking, significant family history, gender, and age dramatically increase the likelihood of health
problems. Smoking affects the entire body, leading to altered oxygenation status and the risk of cancer. A
3. Portion control is key for successful weight loss. By using this method, one can realistically decrease caloric
consumption and build a foundation of food intake based on appropriate portion sizes. Visualization of portions
using commonly known objects such as a deck of cards for a serving of protein will help an individual to
4. Although the presence of fat in certain areas of the body has some association with gender (females typically
have more fat on their hips whereas males have more fat in their stomach area), the idea of spot reducing is
5. The weight-loss business is a multibillion dollar industry that utilizes a combination of products and
psychological methods to induce weight loss. Part of the reason why weight loss accomplishments are hard to
define for the average individual is inconsistent criteria used to denote progress among these methods. There are
6. An individual who is underweight may have significant health concerns, for the body will not be able to sustain
metabolism in the absence of adequate fuel sources. If the person’s food intake is inadequate, her/his body will
break down nutrient stores (if available) to fuel itself. Cellular activity in the body will be compromised, leading
to alterations in energy balance. The functions of the body will be compromised, leading to risk for infection.
Nutrient deficiencies will arise.
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
with wasting due to AIDS or cancer
Monitor for side effects: increased
appetite and weight gain, swelling,
hyperglycemia, headache, breast
tenderness, impotence, decreased
sexual desire, elevated blood pressure
Dronabinol
(Marinol)
Orexigenic
agent
Prevention of nausea/vomiting
during cancer treatment; stimulation
of appetite in AIDS patients
Orlistat
Lipase inhibitor
Weight loss/maintenance in
Monitor for improvement of blood
Monitor for interactions with alcohol
and other depressant medications;
side effects: dizziness,
lightheadedness, or fainting; mental
1. FDA (Food and Drug Administration)
2. Yes
3. See “Monitoring Aspects” column of table.
4. For medications used to promote weight loss or gain, the clinician would monitor the patient’s weight, assess
body composition using appropriate techniques, and check for edema/dehydration (changes in fluid balance). If
5. Sample pricing: Megestrol acetate = $52.99 for 100 40-mg tablets; Marinol = $441.97 for 60 2.5-mg capsules;
Adipex-P = $76.97 for 30 37.5-mg tablets; Xenical = $279.91 for 60 120-mg capsules; alli = $54.79 for “starter
pack” with 90 60-mg capsules
Worksheet 9-2: Clinical Application—Bariatric Surgery12
11 Sources for answer key: Medline Plus: Drugs, Supplements, and Herbal Information. Accessed 4 April 2012 & 8
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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.
Worksheet 9-3: Learn to “Shape Up” (Internet Exercise)
Worksheets 9-4, 9-5, 9-6, and 9-7 – Answers will vary.
Worksheet 9-8: Chapter 9 Crossword Puzzle
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Worksheet 9-1: Weight Management Medications
Medication
Classification
Clinical Indication
Monitoring Aspects
Megestrol
acetate
(Megace)
Orexigenic
agent
For each of the medications listed above, look up both the clinical indications and the monitoring aspects associated
with a client taking this drug for his or her respective weight management issue.
After you have found the information, consider the following questions:
1. Which government agency is involved in the regulation of these medications?
2. Is ongoing monitoring required for the use of these medications?
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Worksheet 9-2: Clinical Application—Bariatric Surgery
Consider the following scenario: Someone told you that she was considering having a “gastric bypass” and asked
you to explain to her exactly what that meant in terms of the surgical procedure and nutritional management. When
considering these questions, identify the resources that are available to people on the Internet.
1. How would you go about finding out about the surgical procedure?
2. What is meant by the term “gastric bypass”?
3. What criteria are used to determine if an individual should have this type of procedure?
4. How much does this procedure cost?
9. First, think of the answers that would be provided by a healthcare provider to a client and secondly, think of the
answers that a client might obtain independent of a healthcare provider. How would the answers differ? How
would you determine the resources’ scientific reliability and validity?