From the Guidelines
The patient should aim for a daily energy deficit of 500-1000 kcal to achieve a weight loss of 1-2 pounds per week, as recommended by the most recent and highest quality study 1. To achieve this, I recommend switching from FiberLax to Metamucil, starting with one rounded tablespoon mixed in 8 ounces of water once daily, gradually increasing to twice daily if needed. This change may help regulate bowel movements as Metamucil contains psyllium husk, which forms a gel in the intestines to normalize stool consistency. For weight management, given the patient's BMI of 40.16 indicating severe obesity, I recommend comprehensive laboratory testing including thyroid function, HbA1c, lipid panel, and liver function tests to rule out metabolic causes of weight retention. While awaiting lab results, the patient should begin food journaling to track all caloric intake, as many patients underestimate their consumption. Despite the patient's current exercise regimen and carbohydrate/sugar restrictions, they may need to consider caloric reduction, portion control, and possibly consultation with a registered dietitian. Some key considerations for the patient's weight management plan include:
- Reducing overall calorie intake by at least 500 kcal/day, with sufficient protein, vitamins, and minerals 1
- Encouraging 30-60 minutes per day of moderate-intensity aerobic exercise, at least 5 days per week 1
- Gradually increasing physical activity over time to reach a target level, tailored to the individual's age, current level of function and physical fitness, and complications/risk factors 1 At the follow-up appointment, we'll review lab results and develop a structured weight management plan, potentially including consideration of weight loss medications or bariatric surgery options if appropriate based on the comprehensive evaluation.
From the FDA Drug Label
Purpose Fiber laxative Active ingredient (in each PACKET (5.8 g)) Psyllium husk approximately 3.4 g The patient's current issue of having 3-5 BMs daily and difficulties with FiberLax may be addressed by switching to Metamucil, which contains psyllium as its active ingredient, a fiber laxative 2.
- The patient's weight loss concerns and current BMI of 40.16 will require further evaluation through labs and a follow-up appointment to develop a plan 2.
From the Research
Patient's Current Situation
- The patient is experiencing 3-5 bowel movements (BMs) daily and has been taking FiberLax for over a year with difficulties.
- The patient is complaining of not losing weight despite working out every day, including cardio and weights, and following a diet that avoids carbs after 1:00 PM and sugar.
- The patient's current BMI is 40.16.
Physical Activity Recommendations
- According to 3, primary care physicians should encourage patients to engage in at least 150-300 minutes per week of moderate-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity.
- Adults should also perform muscle-strengthening activities of moderate intensity or higher that involve all major muscle groups for 2 or more days per week.
Psyllium Supplementation for Weight Loss
- A study published in 4 found that psyllium supplementation, dosed just before meals, was effective for decreasing body weight, BMI, and waist circumference in overweight and obese populations.
- However, another study published in 5 found that psyllium supplementation did not reduce body weight, BMI, and waist circumference significantly.
- A systematic review and dose-response meta-analysis published in 6 found that psyllium consumption significantly reduced triglycerides, low-density lipoprotein, fasting blood sugar, and hemoglobin A1c in diabetic patients, but did not significantly change body mass index, cholesterol, and weight.
Psyllium Supplementation for Bowel Movements
- A study published in 7 found that psyllium supplementation increased stool water and altered the microbial composition of constipated patients, leading to improved bowel movements.
Next Steps
- The patient will be prescribed Metamucil to help regulate their BMs.
- Labs will be ordered and a follow-up appointment will be scheduled to start a plan for weight loss.