Weight Management: Overweight, Obesity, and Underweight
I. Overweight
Overweight (BMI 25-29.9) and obesity (≥ 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
1. Fat cell numbers
a. Fat cell numbers increase most rapidly in later childhood and early puberty.
b. Fat cell numbers increase in times of positive energy balance.
c. Hyperplastic obesity
2. Fat cell size
a. Fat cell sizes increase when energy intake exceeds expenditure.
b. Hypertrophic obesity
3. The adverse effects of fat in non-adipose tissue are called lipotoxicity.
B. Fat Cell Metabolism
1. Lipoprotein lipase promotes fat storage.
2. Gender differences
a. Men are at increased risk for developing central obesity and women are at
increased risk for lower body fat.
b. Enzymes that break down fats affect men and women differently.
C. Set-Point Theory
1. The body’s natural regulatory centers maintain homeostasis at set point.
2. The human body tends to maintain a certain weight.
II. Causes of Obesity
Obesity may not be as simple as food intake exceeding metabolic needs. Some factors, such
as overeating and inactivity, are within our control. Genetic, hormonal and emotional factors
may require professional intervention.
A. Genetics
1. Leptin (also called the ob protein)
a. Protein that acts as a hormone to increase energy expenditure and decrease
appetite
b. Produced by fat cells under the direction of the ob gene
c. May be deficient in obese individuals
d. More research is needed.
2. Ghrelin
a. Protein that acts as a hormone to decrease energy expenditure and increase
appetite
b. Produced by stomach cells
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c. Has an inverse relationship with PYY
3. Uncoupling Proteins
a. Influence energy metabolism
b. White adipose tissue stores fat to be used for energy.
c. Brown adipose tissue stores fat to be used for heat.
d. May oppose the development of obesity
B. Environment – The gene pool of our population remains relatively unchanged.
1. Overeating
a. Present and past eating influences current body weight.
b. Increased availability of convenient food, large portions, and energy-dense foods
2. Physical Inactivity
a. Modern technology replaces physical activities.
b. Physical activity is important to allow people to eat enough food to get needed
nutrients.
III. Problems with 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
c. High LDL
d. Low HDL
e. Impaired glucose tolerance
f. Family history of heart disease
g. Men  45 years, women  55 years
3. Obese or overweight people with the following life-threatening-conditions may
improve health by losing weight:
a. Heart disease
b. Type 2 diabetes
c. Sleep apnea
B. Perceptions and Prejudices
1. Social Consequences
a. Prejudices and discrimination
b. Judged on appearance rather than character
c. Stereotyped as lazy and lacking self-control
2. Psychological Problems
a. Feelings of rejection, shame and depression are common.
b. Ineffective treatments can lead to a sense of failure.
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C. Dangerous Interventions
1. Fad Diets
a. False theories
b. Inadequate diets
c. Can be a danger to health
d. \Ttypes of weight loss diets
 Low Carbohydrate aka High Protein
 Low Fat aka High Carbohydrate
 Very Low Calorie aka Modified Fast
 Novelty Diets
 Weight Loss Programs
e. Why weight Loss Programs do not work
 Negative Impact
 Temporary
 Perfect- Orientation
 Project Mentality
 Do not Address Cause
f. Consequences of Dieting
 Decrease in rate of weight loss
 Loss of lean tissue with fat loss
 Decrease in metabolism, 10-40%
 Decrease in Protein turnover
 Preoccupation with food
 Increase in irritability, moodiness
 Tires easier, less physical activity
 Apathy, depression
g. Re-Feeding after weight loss
 Increase in pre-dieting food intake
 Preference for high fat foods
 Regain in weight, but greater increase in % BF
 Metabolism slow to return to normal
 Regain Weight quicker with each diet
 Increase in abdominal fat deposits
 Less likely to return to pre-diet physical activity
 Decrease in self-efficacy/esteem
h. Recognizing an unsound diet
 Promotes Quick Weight Loss
 Limits Food Selection
 Testimonials or Famous People/Places
 Expensive Supplements or Products
 No Attempt to Permanently change eating or
physical activity
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 Critical of Scientific Community‘
 They know more, or something new
i. Characteristics of a Sound Diet
 Nutritionally adequate yet low in calories
 Fit into current lifestyle
 Foods that are liked
 Slow rate of weight loss
 Followed for life
D.. Predicting Weight Loss Success
1. Positive Affirmations
a. Self esteem
b. Self confidence
c. Good attitude
d. Positive outlook
2. Strong Motivation
a. Desire or want
b. Belief it is possible
c. Commitment to doing it
d. Positive attitude
e. Persistence
3. Supportive Environment
a. Family and friends
b. Support group or organization
c. Professional
4. Appropriate Behaviors
a. Healthy eating
b. Exercise that produces goal
c. Changing problem behaviors
5. Changes in Body Shape
a. Body Composition changes
b. Circumference changes
c. “Looks better”, Cloths fit better, etc.
2. Weight-Loss Products
a. Ephedrine-containing products inhibit serotonin and suppress the appetite.
Supplements containing Ephedra have been banned by the FDA due to potential
health risks.
b. Herbal laxatives do not prevent absorption.
c. Current laws do not require safety tests and effectiveness tests for these products.
3. Other Gimmicks
a. Don’t work
b. There is no such thing as cellulite.
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IV. Weight-Loss Strategies
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
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.
3. Smaller portions are recommended to feel satisfied, not stuffed.
4. Eat foods of lower energy density, that are high in fiber, high in water and low in fat.
5. Water is important to increase fullness and reduce hunger.
6. Complex carbohydrates offer abundant vitamins, minerals and fiber with little fat.
7. Choose fats sensibly and reduce the quantity of fat.
8. Watch empty kcalories from sugar and alcohol.
B. Physical Activity
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.
4. Activity can decrease body fat and increase lean body mass.
5. Exercise may help to curb appetite.
6. Activity can reduce stress and improve self-esteem.
7. Choosing Activities
a. Choose activities that you enjoy and are willing to do regularly.
b. Low to moderate intensity for long duration is recommended.
c. Daily routines can incorporate energy activities.
8. Spot Reducing
a. Regular aerobic exercise and weight loss will help trouble spots.
b. Strength training can improve muscle tone.
c. Stretching can help flexibility.
C. Behavior and Attitude
1. Behavior modification requires time and effort.
2. Awareness of behavior is the first key.
3. Changing behaviors one at a time works best.
a. Do not grocery shop when hungry.
b. Eat slowly.
c. Exercise while watching television.
4. Personal attitudes toward food and eating must be understood.
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5. Support groups may be helpful for some people.
Aggressive Treatments of 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.
D. Drugs
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.
3. Other drugs are still under study.
E. Surgery
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.
2. Gastric surgery has short-term and long-term problems and requires compliance with
dietary instructions.
3. Liposuction is a popular procedure that is primarily cosmetic but poses risk.
F. Weight Maintenance
1. Successful weight-loss maintenance programs use different criteria so they are
difficult to compare.
2. Vigorous exercise and careful eating plans are key.
3. Frequent self-monitoring is recommended.
a. Food diary
b. Exercise Journal
c. Weekly weight
d. Circumference changes
G. Prevention
1. Eat regular meals and limit snacking.
2. Drink water in place of high-kcalorie beverages.
3. Select sensible portion sizes and limit daily energy intake to energy expended.
4. Limit sedentary activities and be physically active.
H. Public health programs have been suggested to:
1. Develop safety standards for foods.
2. Control commercial advertising.
3. Control conditions under which foods are sold.
4. Control prices to reduce consumption.
G. Predicting Weight Loss Success
6. Positive Affirmations
a. Self esteem
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b. Self confidence
c. Good attitude
d. Positive outlook
7. Strong Motivation
a. Desire or want
b. Belief it is possible
c. Commitment to doing it
d. Positive attitude
e. Persistence
8. Supportive Environment
a. Family and friends
b. Support group or organization
c. Professional
9. Appropriate Behaviors
a. Healthy eating
b. Exercise that produces goal
c. Changing problem behaviors
10. Changes in Body Shape
a. Body Composition changes
b. Circumference changes
c. “Looks better”, Cloths fit better, etc.
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.
2. Energy demands may be great and foods are needed to support growth and physical
activities.
3. Eating disorders are severe cases.
B. Weight-Gain Strategies
1. Energy-dense foods can be included but choose fat wisely to avoid the associated
cardiac risks.
2. Regular meals each day must become a priority.
3. Use large portions and expect to feel full.
4. Consume extra snacks between meals.
5. Juice and milk are easy ways to increase kcalories.
6. Exercising to build muscles will support increases in muscle mass.
VI. The Latest and Greatest Weight-Loss Diet Again
Fad diets do not offer safe or effective plans for weight loss. Diet recommendations should
be research based. There are guidelines for identifying fad diets and weight-loss scams.
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A. The Diet’s Appeal
1. There are many misconceptions and distortions of facts.
2. Results are not long lasting.
B. The Diet’s Achievements
1. Don’t Count kCalories
2. Satisfy Hunger
3. Follow a Plan
4. Limit Choices
C. The Diet’s Shortcomings
1. Too Much Fat
2. Too Much Protein
3. Too Little of Everything Else
D. The Body’s Perspective – Adverse side effects of low-carbohydrate, ketogenic diets
1. Nausea
2. Fatigue
3. Constipation
4. Low blood pressure
5. Elevated uric acid
6. Stale, foul taste in the mouth
7. Fetal harm and stillbirth
1. Describe how body fat develops and suggest some reasons why it is difficult for an obese
person to maintain weight loss.
2. What factors contribute to obesity?
3. List several aggressive ways to treat obesity and explain why such methods are not
recommended for every overweight person.
4. Discuss reasonable dietary strategies suitable for achieving and maintaining a healthy
body weight.
5. What are the benefits of increased physical activity in a weight-loss program?
6. Describe the behavioral strategies recommended for changing an individual’s dietary
habits. What role does personal attitude play?
7. Describe strategies for successful weight gain.
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Weight Management Medications1
Medication
Classification
Clinical Indication
Megestrol
Orexigenic
Treatment of metastatic
acetate
agent
breast cancer, metastatic
(Megace)
endometrial cancer;
stimulation of appetite and
promotion of weight gain in
patients with wasting due to
AIDS or cancer
Dronabinol
Orexigenic
Prevention of nausea/
(Marinol)
agent
vomiting during cancer
treatment; stimulation of
appetite in AIDS patients
Sibutramine
hydrochloride
monohydrate
(Meridia)
Orlistat
(Xenical)
Norepinephrine, Weight loss/ maintenance in
serotonin and
overweight patients
dopamine
inhibitor
Lipase inhibitor Weight loss/ maintenance in
overweight patients
Monitoring Aspects
Monitor for side effects:
increased appetite and weight
gain, swelling,
hyperglycemia, headache,
breast tenderness, impotence,
decreased sexual desire,
elevated blood pressure
Monitor for interactions with
alcohol and other depressant
medications; side effects:
dizziness, lightheadedness, or
fainting; mental disturbances
Monitor for side effects:
elevated blood pressure or
heart rate, allergic reactions,
dizziness, drowsiness
Monitor for improvement of
blood glucose in diabetic
patients; monitor for
compliance with fat-restricted
diet and daily multivitamin
supplement
.
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Eating Attitudes Test
Answer these questions using the following responses:
A = Always
U = Usually
O = Often
S=
Sometimes
R = Rarely
N = Never
Response
_____
Score*
_____ 1. I am terrified about being overweight.
_____
_____ 2. I avoid eating when I am hungry.
_____
_____ 3. I find myself preoccupied with food.
_____
_____ 4. I have gone on eating binges where I feel that I may not be able to stop.
_____
_____ 5. I cut my food into very small pieces.
_____
_____ 6. I am aware of the calorie content of the foods I eat.
_____
_____ 7. I particularly avoid foods with a high carbohydrate content.
_____
_____ 8. I feel that others would prefer if I ate more.
_____
_____ 9. I vomit after I have eaten.
_____
_____ 10. I feel extremely guilty after eating.
_____
_____ 11. I am preoccupied with a desire to be thinner.
_____
_____ 12. I think about burning up calories when I exercise.
_____
_____ 13. Other people think I am too thin.
_____
_____ 14. I am preoccupied with the thought of having fat on my body.
_____
_____ 15. I take longer than other people to eat my meals.
_____
_____ 16. I avoid foods with sugar in them.
_____
_____ 17. I eat diet foods.
_____
_____ 18. I feel that food controls my life.
_____
_____ 19. I display self-control around food.
_____
_____ 20. I feel that others pressure me to eat.
_____
_____ 21. I give too much time and thought to food.
_____
_____ 22. I feel uncomfortable after eating sweets.
_____
_____ 23. I engage in dieting behavior.
_____
_____ 24. I like my stomach to be empty.
_____
_____ 25. I enjoy trying new rich foods.
_____
_____ 26. I have the impulse to vomit after meals.
_____
*Scoring:
10
Total score
3 for never, 2 for rarely, 1 for sometimes, 0 for always, usually and often.
Total scores under 20 points indicate abnormal eating behavior.
Exploring Eating Habits
To explore your eating habits, check all the answers that describe your food intake patterns.
Then, consider possible areas for improvement.
When do I usually eat?
_______ At mealtime.
_______ While studying.
_______ While preparing meals or clearing the table.
_______ When spending time with friends.
_______ While watching TV or participating in other activities.
_______ Anytime.
Where do I usually eat?
_______ At home at the kitchen or dining room table.
_______ In the school cafeteria.
_______ In fast-food places.
_______ In front of the TV or while studying.
_______ Wherever I happen to be when I’m hungry.
Why do I usually eat?
_______ It’s time to eat.
_______ I’m hungry.
_______ Foods look tempting.
_______ Everyone else is eating.
_______ Food will get thrown away if I don’t eat it.
_______ I’m bored or frustrated.
Changes I want to make:
Source: U.S. Department of Agriculture, Dietary Guidelines and Your Health: Health Educator’s
Guide to Nutrition and Fitness (Washington, DC, US Government Printing Office, 1992).
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Exploring Food and Activity Choices
Does your BMI fall between 18.5 and 24.9? If so, you may want to maintain your weight. If not, you may
need to gain or lose weight to improve your fitness and health. Determine whether these food and activity
choices are typical of your lifestyle.
Food and activity choices
Frequency per week
Promote weight gain:
Drink plenty of juice.
Eat energy-dense foods.
Eat large portions.
Eat peanut butter crackers between meals.
Eat three or more large meals a day.
Promote weight loss:
Drink plenty of water.
Eat nutrient-dense foods.
Eat slowly.
Eat small portions.
Limit snacks to healthful choices.
Limit television watching.
Participate in physical activity.
Select low-fat foods.
Share a restaurant meal or take home leftovers.

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On the average, do your lifestyle choices promote weight gain, weight loss, or weight
maintenance?
Very-Low-kCalorie Diets
Very-low-kcalorie-diets (VLCD) provide 800 kcalories, at least 1 gram of high-quality protein, per
kilogram of body weight, little or no fat, and a minimum of 50 grams of carbohydrate (not enough to
spare protein). Clients receive an assortment of vitamins and minerals from supplements. VLCD formulas
are designed to be nutritionally adequate, but the body responds to this severe energy restriction as if the
person were starving—conserving energy and preparing to regain weight at the first opportunity. Several
changes occur in hormone concentrations, metabolic activities, fluid and electrolyte balances, and organ
functions in the effort to meet the challenge of living on a much-less-than-adequate energy intake. For
these reasons, a VLCD is appropriate only for short-term use (four months) and under close medical
supervision. The table lists common side effects of VLCD. Weight losses on VLCD are dramatic.
Unfortunately, weight regains are almost certain. With weight loss comes a slower BMR and slower fat
oxidation—conditions that favor weight gain. Such rapid losses followed by steady gains are detrimental
to both physical and psychological health.
Possible Physical Consequences of Very-Low-kCalorie Diets
Blood
 Blood carotene concentrations increase.
 Blood cholesterol concentrations increase.
 Blood urea concentrations increase.
Cardiovascular/Respiratory
 Blood pressure declines.
 Carbon dioxide production declines.
 Cardiac output declines.
 Heart muscle atrophies.
 Heartbeat becomes irregular.
 Oxygen consumption declines.
 Pulse rate declines.
 Respiratory rate declines.
Digestive
 Gallstones and kidney stones form.
 GI tract motility declines.
 Liver inflammation and fibrosis develop.
 Nausea, vomiting, diarrhea, abdominal
discomfort, and constipation occur.
Hormonal
 Menstrual irregularity develops.
 Sex drive is lost.
Immunity
 Immune response diminishes.
 White blood cells decrease in number.
Metabolic
 Basal metabolism declines.
 Bone mineral content shifts.
 Cold intolerance occurs.
 Dehydration may occur.
 Gout may occur.
 Ketosis develops.
 Lean body tissues are lost.
 Mineral and electrolyte imbalances occur.
 Nitrogen balance becomes negative.
Other
 Body and breath odor (from ketone excretion)
may become apparent.
 Hair falls out.
 Headaches occur.
 Lethargy, fatigue, and loss of stamina set in.
 Skin dries out.
 Sleeplessness may occur.
 Sudden death becomes possible.
Sources: C. J. Field, R. Gougeon, and E. B. Marliss, American Journal of Clinical Nutrition 54 (1991):
123-129; K. N. Pavlou and coauthors, American Journal of Clinical Nutrition 49 (1989): 1115-1123; R.
L. Atkinson, Low calorie diets and obesity, in Biotechnology and Nutrition, eds. D.D. Bills and S. D.
Kung (Boston: Butterworth-Heinemann, 1992), pp. 29-45.
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How to Change Behaviors to Support Weight Loss
1. To eliminate inappropriate eating cues:
• Buy foods that are low in fat.
• Shop when you are not hungry.
• Serve low-fat meals.
• Let other family members buy, store, and serve their own sweets (monitor children’s intakes).
• Change channels or look away when food commercials appear on television.
• Shop only from a list and stay away from convenience stores.
• Carry appropriate snacks from home and avoid vending machines.
2. To suppress the cues you cannot eliminate:
• Eat only in one place (at a table), and in one room; use plates, bowls, and eating utensils.
• Clear plates directly into the garbage.
• Create obstacles to the eating of problem foods (make it necessary to unwrap, cook, and serve
each one separately).
• Minimize contact with excessive food (serve individual plates, don’t put serving dishes on the
table, and leave or clean the table when you have finished eating).
• Make small portions of food look large by spreading food out and serving on small plates.
• Control deprivation (eat regular meals, don’t skip meals, avoid getting tired, avoid boredom by
keeping cues to fun activities in sight).
3. To strengthen the cues to appropriate eating and exercise:
• Encourage others to eat appropriate foods with you.
• Keep your favorite appropriate foods in the front of the refrigerator.
• Learn appropriate portion sizes and prepare one portion at a time.
• Establish specific times for meals and snacks.
• Prepare foods attractively.
• Keep your walking shoes (ski poles, tennis racket) by the door.
4. To engage in desired eating or exercise behaviors:
• Eat only at planned times; plan not to eat after a specified time (say, 7:00 or 8:00 p.m.).
• Slow down (pause several times during a meal, put down utensils between mouthfuls, chew
thoroughly before swallowing, swallow before reloading the fork, always use utensils).
• Leave some food on the plate.
• Engage in no other activities while eating (such as reading or watching television).
• Move more (shake a leg, pace, fidget, flex your muscles).
• Join in and exercise with a group of active people.
5. To arrange or emphasize negative consequences of inappropriate eating:
• Eat your meals with other people.
• Ask that others respond neutrally when you deviate from your plan (make no comment). This is a
negative consequence because it withholds attention.
• If you slip, don’t punish yourself.
6. To arrange or emphasize positive consequences of appropriate behaviors:
• Update records of food intake, exercise, and weight change regularly.
• Arrange for rewards for each unit of behavior change or weight loss.
• Ask family and friends for reinforcement (praise and encouragement).
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