7. Assessment of people living with obesity Flashcards
1
Q
what is the objective of an obesity assessment?
A
-confirm diagnose
-determine the severity
-identify triggers and drivers
-guide appropriate management discussions
2
Q
what do you initiate a discussion with the patient?
A
about their values and goals for treatment
3
Q
what is the definition of obesity?
A
a complex chronic disease in which abnormal or excess
body fat (adiposity) impairs health, increases the risk of long-term
medical complications and reduces lifespan
4
Q
An adaptation
of the 5As’ template has been developed by Obesity Canada for
use in clinical practice. The main components of this framework
include:
A
- ASKING for permission to discuss weight and explore readiness;
- ASSESSING obesity-related risks and root causes of obesity;
- ADVISING on health risks and treatment options;
- AGREEING on health outcomes and behavioural goals; and
- ASSISTING in accessing appropriate resources and providers.
5
Q
Finally, when conducting an obesity assessment and in order to
achieve long-term success, it is important to assess what?
A
readiness to change, intrinsic motivation and value and goals
6
Q
the BMI can be misleading and needs to
be interpreted with caution in what populations?
A
the elderly, very muscular patients and those with
extreme tall or short stature
7
Q
what is BMI for overweight (increased risk and requires further evaluation)?
A
25 and over;
23 and over for S, SE, E Asians
8
Q
WC has been
independently associated to increase what risk?
A
cardiovascular risk
9
Q
WC is not a good predictor of what?
A
visceral adipose tissue
10
Q
how to measure height and weight?
A
barefoot, in light clothing;
nearest 0.1kg and 1cm;
standardized tech and equipment by trained professionals
11
Q
how to calculate BMI?
A
weight divided by the square of the body height in meters (kg/m2)
12
Q
what is underweight BMI?
A
<18.5
13
Q
what is the limitation of BMI?
A
- BMI is not a direct measure of body fat, cardiovascular risk or
health. - BMI does not indicate body fat distribution.
- BMI does not account for muscle mass (it overestimates body
fat in muscular individuals). - BMI can underestimate body fat in people who have lost muscle
mass (sarcopenic obesity). - BMI does not distinguish between men, women or ethnicity.
- BMI is less accurate in certain populations (e.g., the elderly, people
with physical disability, people <18 years of age, people with
severe obesity, during pregnancy and in patients with ascites or
severe edema). - BMI over- or underestimates body fat in certain ethnic groups,
such as Indigenous Peoples, South Asians, Chinese and other
populations.
14
Q
the use of WC has been recommended as a surrogate measure of …
A
abdominal or visceral fat
15
Q
how to measure WC?
A
- Remove clothing from the waistline.
- Stand with feet shoulder width apart (25 to 30 cm or 10 to 12 inches) and a straight back.
- Palpate the abdomen to locate inferior margin of the
last rib at the level of the mid-axillary line. - Palpate and identify the crest of the ileum in both sides.
Use the area between the thumb and index finger to
feel for the hip bone at the level of the mid-axillary line.
This is the part of the hip bone at the side of the waist,
not at the front of the body. - WC should be measured at the end of a normal expiration, midway between the inferior margin of the last rib and the crest of the ileum in a horizontal plane using a stretch-resistant tape that provides a constant 100 g
tension and should be recorded to the nearest 1 cm. - Have the patient take two normal breaths, and on the
exhale of the second breath tighten the tape measure so
it is snug but not digging into the skin.
16
Q
what is the indication of increased risk of visceral adiposity and of developing cardiometabolic comorbidities in terms of WC?
A
WC equal or over 102 cm (men);
88 cm (in women)
Asian - 85 in men, 75 in women
17
Q
what is the limitation of WC?
A
- WC is not a direct measure of visceral fat.
- Considerable training and standardization are required to ensure
inter- and intra-reader reproducibility. - WC is sensitive to abdominal distention due to food or fluid
intake, bloating, ascites, pregnancy, etc - Varying cut-offs for ethnic populations.
- Less sensitive measure of visceral fat with increasing BMI.
- WC requires further body exposure and can be perceived as an
intrusive measurement by some patients.
18
Q
who is at increased risk of developing cardiometabolic risk factors, such as diabetes mellitus type 2 and hypertension?
A
6 Patients
with an increased BMI (< 35 kg/m2) and an elevated WC
19
Q
Those with a BMI > 35 kg/m2 are likely to be at an increased risk
of ?
A
cardiometabolic risk factors irrespective of their WC.
20
Q
why is it good to measure WC in patients with BMI >35 kg/m2?
A
valuable information regarding
the efficacy of their treatment during their long-term follow-up.
Some patients can see changes in adipose distribution before a
significant change in body weight or BMI.
21
Q
what are some non-metabolic conditions associated with obesity?
A
sleep apnea, depression and joint/back pain
22
Q
EOSS is a measure of the 3 different impact that obesity has had on the patient’s health. what are they?
A
mental, metabolic, physical impact
23
Q
what stages do EOSS have?
A
0-4 stages
24
Q
what is structured interview formats, 5As?
A
- Ask for permission to discuss
- Assess risks and root causes
- Advise health risks and treatment options
- Agree on health outcomes and goals
- Assist in accessing appropriate resources and providers
25
what is stage 0 of EOSS?
No apparent obesity-related risk factors (e.g.,
blood pressure, serum lipids, fasting glucose, etc.
within normal range), no physical symptoms, no
psychopathology, no functional limitations and/
or impairment of wellbeing
26
what is stage 1?
Presence of obesity-related subclinical risk factors
(e.g., borderline hypertension, impaired fasting
glucose, elevated liver enzymes, etc.), mild physical
symptoms (e.g., dyspnea on moderate exertion,
occasional aches and pains, fatigue, etc.), mild
psychopathology, mild functional limitations
and/or mild impairment of wellbeing
27
what is stage 2?
Presence of established obesity-related chronic
disease (e.g., hypertension, type 2 diabetes,
sleep apnea, osteoarthritis, reflux disease, polycystic ovary syndrome, anxiety disorder, etc.),
moderate limitations in activities of daily living
and/or wellbeing
28
what is stage 3?
Established end-organ damage such as myocardial
infarction, heart failure, diabetic complications,
incapacitating osteoarthritis, significant psychopathology, significant functional limitations and/
or impairment of wellbeing
29
what is stage 4?
Severe (potentially end-stage) disabilities from
obesity-related chronic diseases, severe disabling
psychopathology, severe functional limitations
and/or severe impairment of wellbeing
30
if patient is obese and has hypertension and diabetes, what stage is this person in, and what is the management?
stage 2;
initiation of obesity treatment, including all psycho interventions, pharmacological and surgical treatment options;
close monitor and manage comorbidities as indicated
31
if the person with obesity has diabetes complications, what stage is the person in, and what is the management?
stage 3;
more intensive obesity treatment including all psycho interventions, pharmacological and surgical treatment options;
aggressive management of comorbidities as indicated
32
the patient with obesity has impaired fasting glucose, and mild physical symptoms, what stage is this person in, and what is the management?
stage 1;
investigate for other (non-weight-related) risk factors, more intense behavioural interventions, including nutrition therapy, exercise and psychological treatments to prevent further weight gain;
monitor risk factors and health status
33
what is the goal for assessment?
1. identify causes
2. determine the extent to which weight has affected the patients' health
3. find barriers in their management
34
what is 4M framework that can provide a practical approach for primary care physicians to explore major drivers, barriers, and complications of obesity?
Mental health
Mechanical
Metabolic
Monetary health/Milieu
35
what are some complications of mental health that you need to explore with the patients in order to assess obesity?
knowledge/cognition;
expectations;
self-image;
internalized weight bias;
mood/anxiety;
addiction;
sleep;
attention;
personality
36
how to investigate mood & anxiety?
PHQ-9, GAD
37
how to investigate food addiction?
Yale Food Addiction Scale
38
what is the question to ask for internalized weight bias investigation?
how your weight affects your perception of yourself?
39
what are some complications of mechanical health that you need to explore with the patients in order to assess obesity?
osteoarthritis & gout;
sleep apnea;
plantar fasciitis;
GERD;
urinary incontinence;
intertrigo;
idiopathic intracranial hypertension (Pseudotumour Cerebri);
Thrombosis
40
if patient has gout and obese, what medication should be avoided if possible?
steroids
41
what do you assess for gout in obese patient?
uric acid level
42
what do you use for sleep apnea assessment?
STOP BANG sleep apnea questionnaire,
Berlin questionnaire;
overnight sleep study
43
what are some complications of metabolic health that you need to explore with the patients in order to assess obesity?
type 2 diabetes;
hyperlipidemia;
nutritional deficiency;
gout;
hypertension;
endocrine - PCOS/hypogonadism, infertility;
cardiovascular disease;
GI disease - fatty liver, gallstones;
oncology;
skin - acanthosis, skin tags, candida, intertrigo, tinea, folliculitis
44
what are some nutritiional deficiencies that you need to check for obesity?
25 hydroxy-vitamin D, iron studies, serum B12 level
45
what investigation should be done for type 2 diabetes?
A1C, fasting glucose
46
what are better anti-hypertensive med for obese people?
meds that affect the renin-angiotensin system;
avoid b-blockers as first line
47
what hormones to check for infertility?
total testosterone, estradiol, prolactin, 17 hydroxyprogesterone, LH/FSH, DHEAS, TSH if clinical suspicion of hypothyroidism
48
what are cardiovascular diseases that you need to investigate for obesity?
left ventricular hypertrophy, atrial fibrillation;
chronic venous stasis/ulcers/thrombophlebitis;
stroke, DVT/PE;
Neurological;
Pseudotumor cerebri
49
what do you need to investigate for GI disease?
fatty liver;
gallstones;
labs - liver enzyme elevation, increased liver stiffness (elastography) abdominal ultrasound, FIB-4 score
50
what are some increased risk of cancer in obesity?
Colorectal, gallbladder,
pancreatic, breast, renal,
uterine, cervical, prostate
51
what are Monetary
Health/ ”Milieu” to investigate?
Socioeconomic status
Education
Access to food
Occupation
Disability
Clothing
Weight loss programs
Access to pharmacotherapy
Surgery
Vitamins
52
Key elements
of the history include...
screening for sleep disorders; physical, sexual
and psychological abuse; description of eating patterns; physical activity and screen time; internalized weight bias; mood and anxiety
disorders; as well as substance abuse and addiction
53
The clinician conducting the assessment should also identify and document the patient’s --- and --- around treatment and foster insight to help with long-term coping and self-management skills
values and goals
54
what are interview components?
weight history;
nutrition history;
physical activity;
depression and anxiety screening;
other mental health issues/drivers;
addition/dependency;
abuse;
sleep history;
medication history;
social history;
family history;
interpersonal assessment
55
An obesity-centred physical exam should be focused on determining what?
the obesity phenotype, drivers of weight gain and treatment barriers for all patients
56
which lab tests are considered for most patients?
HbA1c;
creatinine, eGFR;
TC, HDL, LDL, TG;
ALT;
age-appropriate cancer screening
57
which lab tests are considered only if clinically indicated?
* Complete (full) blood count
* Thyroid stimulating hormone/thyroid function tests
* Uric acid
* Assessment of iron (TIBC, % saturation, serum ferritin, serum iron)
* Vitamins B12 and D levels
* Urinalysis
* Urine for micro-proteinuria
58
Women with obesity and symptoms of polycystic ovary syndrome, what labs should be done?
* LH, FSH, total testosterone, DHEAS, prolactin and 17 hydroxyprogesterone levels
59
what are antihyperglycemics that can cause weight gain?
insulin,
pioglitazone,
glipizide, glyburide, glimepiride,
chlorpropamide, tolbutamide, gliclazide;
repaglinide
60
what are some antidepressants that cause weight gain?
amitriptyline, doxepin, imipramine, nortriptyline, mirtazapine, phenelzine, tranylcypromine,
sertraline, paroxetine, citalopram, escitalopram, fluoxetine, lithium
61
what SSRI is used for less weight gain effect?
fluvoxamine
62
which antipsychotics can cause weight gain?
Haloperidol
Loxapine
Clozapine
Chlorpromazine
Fluphenazine
Risperidone
Olanzapine
Quetiapine
Iloperidone
Sertindole
63
which antipsychotics tend to not cause weight gain?
Ziprasidone
Lurasidone
Aripiprazole
64
which antidepressants (other than SSRI) cause less weight gain?
Bupropion
Nefazodone
Duloxetine
Venlafaxine
Desvenlafaxine
Trazodone
Levomilnacipran
Vilazodone
Vortioxetine
Selegiline (topical MAOIs)
65
which anticonvulsants cause wt gain?
Valproic Acid
Carbamazepine
Gabapentin
66
which anticonvulsants tend not to cause wt gain?
Topiramate
Zonisamide
Lamotrigine
67
which steroid can cause wt gain?
Prednisone
Prednisolone
Cortisone
Ciclesonide
Fluticasone
68
which steroid can less cause wt gain?
Budesonide
NSAIDs
69
which hypertensive meds can cause wt gain?
Propranolol
Metoprolol
Atenolol;
clonidine
70
what the marker of choice in patients with obesity
because of greater energy emission, which generates better images?
technetium sestamibi
71
which is the nuclear imaging technique of choice for patients with obesity?
PET rubidium
72
Standard stress test performance is limited in patients with obesity
for a number of factors - which are?
ECG modification might limit accurate interpretation. Aerobic capacity is diminished because of pulmonary
dysfunction, orthopaedic limitations and left ventricular diastolic
dysfunction. Many patients with obesity fail to achieve 80–85%
of the age-predicted heart rate needed for diagnostically valid results.
Patients with obesity may also
experience mobility, joint and balance issues limiting their ability
to use a treadmill.
73
what do you need to interview for weight history?
Document age of onset of obesity and major weight trajectories
over time
Previous weight loss attempts and response to interventions
(including behavioural interventions, medications, endoscopic
and surgical interventions)
Highest and lowest weight
Major life event(s) associated with weight change
Current phase of weight (e.g., gaining, losing, stable)
74
what do you need to interview for nutritional history?
Assess nutrition literacy
Assess energy intake
Identify current nutritional restrictions (Celiac disease, allergies)
75
what do you need to interview for physical history?
Current physical activity including time spent in sedentary
activities
Limitations to activity (e.g., pain, time, motivation)
Identify social limiting factor restricting access to increasing
physical activity
76
Other mental health
issues/drivers to assess?
Screen for attention deficit hyperactivity disorder, post-traumatic
stress disorder, chronic grief
Psychological impact of previous weight journey
77
Addiction/
dependency ?
Smoking status
Alcohol intake
Use of cannabinoids and other psychoactive substances
Current or previous abuse of substance
Excessive use of caffeine-containing beverages (e.g., sugar sweetened beverages)
78
Sleep history
Number of hours of sleep per night
Use of pharmacologic sleeping aids
Sleep apnea-hypopnea screening (such as STOP BANG Sleep
Apnea Questionnaire)
79
Social history
Age, sex, ethnicity, marital status,
occupation/work schedule: number of hours per week, night
shift work
Income support, medical coverage, access to exercise facilities
Level of functional independence
80
Interpersonal
assessment
Motivation
Confidence
Readiness to change
Expectations
81
