ABOM Flashcards
ABOM
1
Q
where is folate absorbed?
A
jejunum
2
Q
2 manifestations of vitamin A deficiency
A
- night blindness
- follicular hyperkeratosis
3
Q
pharmacotherapy of post-gastric bypass hypoglycemia (4 types)
A
- acarbose (complex disaccharide)
- octreotide (somatostatin analog)
- CCB
- diazoxide
*note: initial therapy is a low carb mixed diet
4
Q
2 cons of using calipers to measure body fat percentage
A
- user variability
- not accurate at higher BMIs
5
Q
what is a positive Stemmer’s sign?
A
pinch upper surface of 2nd toe –> POSITIVE when you cannot pinch the skin —> lymphedema
Negative: can pinch the skin —> lipedema
6
Q
how do green tea extract and hydroxycitric acid aid weight loss?
A
increasing fat oxidation
7
Q
how do guarana and country mallow aid weight loss?
A
increasing energy expenditure
8
Q
how do white kidney bean extract and ginseng aid weight loss?
A
increasing carbohydrate metabolism
9
Q
how long to delay pregnancy after bariatric surgery?
A
12 - 18 months or until a stable post-procedure weight is achieved
10
Q
where is GLP secreted?
A
L cells in the ileum and colon
11
Q
RYGB is the bariatric surgery of choice in patients with what medical conditions?
A
- moderate to severe GERD
- hiatal hernia
- esophagitis
- Barrett’s esophagus (intestinal metaplasia)
12
Q
clinical features of Albright-Hereditary Osteodystrophy
A
Albright-Hereditary Osteodystrophy
Autosomal dominant
Low height (short stature)
Bradydactyly (short 4th and 5th)
Ganglia calcifications (basal ganglia)
Hypogonadism pseudoHypoparathyroidism
13
Q
genetic syndrome associated with pseudohypoparathyroidism (low Ca, elevated Phos and PTH)
A
Albright-Hereditary Osteodystrophy
14
Q
weight loss supplement associated with indigestion, bloating, and constipation
A
chitosan
15
Q
Growth curves and weight gain in chidlren
A
Endocrinopathies: increased weight with decreased height velocity
Overeating: Matching increase in weight and height
MC4 Def: increased weight with steady (but not proportional) increase in height
16
Q
max dose of Contrave
A
Naltrexone/Bupropion
A total daily dosage of two CONTRAVE 8 mg/90 mg tablets twice daily (32 mg/360 mg)
**not a controlled substance!
17
Q
how does testosterone replacement improve metabolic parameters
A
- improved glucose control
- improved cholesterol
- decreased weight circumference
- weight loss
**But decreases fertility
18
Q
class of medication which inhibits breakdown of incretins GLP1 and GIP
A
DPP-4 inhibitors
19
Q
what percent body fat meets criteria for obesity? (males and females)
A
25% in males, 32% in females
20
Q
Mutation/inheritance and clinical manifestations of Cohen syndrome
A
AR/Chromosome 8q22 mutation
Open mouth appearance
Hypotonic & Hairy (thick eyebrows, hair, and eyelashes)
Eye problems
Narrow limbs & neutropenia
21
Q
diagnostic criteria for metabolic syndrome
A
3 of the following:
- Waist > 102 cm (men), 88 cm (women)
- TG > 150
- HDL < 40 (men), 50 (women)
- BP > 130/85
- FBG > 100
22
Q
first order neurons in the anorexigenic pathway
A
POMC/CART
23
Q
leptin inhibits what first order neurons
A
NPY/AGRP neurons of the orexigenic pathway
24
Q
difference between PREbiotics and PRObiotics
A
prebiotics: indigestible oligosaccharides that may stimulate healthy intestinal bacterial growth
probiotics: “healthy bacteria” such as lactobacilli
25
when can you start DOAC or VKA after bariatric surgery
after at least 4 weeks of parenteral therapy
26
contraindications and special indications for Plenity (cellulose and citric acid hydrogel)
any GI structural abnormalities that may inhibit transit or motility
- may be used with breast-feeding mothers
27
indirect costs related to excess weight
1.absenteeism (not at work)
2. presenteeism (decreased productivity)
3. premature disability
4. mortality
28
most common genetic finding in patients with obesity in the general population
FTO variant gene expression
29
USDA recommended distribution range of fat intake (%), protein intake (%), and carb intake (%)
fat 25-35%
protein 10-35%
carb 45-65%
30
contraindications to bariatric surgery
1. ongoing substance abuse (within 1 YEAR)
2. current or planned pregnancy within 12-18 months
3. medically correctable causes of obesity
4. any condition that prevents adherence to the post-op regimen
31
effect of oxyntomodulin on hormone secretion
- agonist effect on GLP1
- co secreted with GLP1
- BUT, increases glucagon
32
perifollicular hemorrhage is associated with what vitamin deficiency
Vitamin C (scurvy)
33
when does post-gastric bypass hypoglycemia typically present after bariatric surgery
1 year after surgery
34
dumping syndrome occurs how soon after a meal
- early; within 15-30 minutes
- late: 1-4 hours hypoglycemia aka post-prandial hypoglycemic hypersulinemia
35
how does sleep deprivation affect leptin levels
DECREASED leptin --> increased appetite and reduced energy expenditure
36
when to stop estrogen products before bariatric surgery
one cycle of OCPs or 3 weeks of HRT
37
Total energy expenditure (TEE) is made up of what components
1. resting energy expenditure (60-75%)
2. physical activity (15-30%)
3. thermic effect of meals (10%)
38
calculation to determine percent body fat
fat mass / (total body mass - bone mass)
39
calculation to determine total body mass
fat mass + lean mass + bone mass
40
calculation to determine fat free mass
total mass - fat mass
41
average daily dietary intake of a nutrient that is sufficient to meet the requirements of nearly all healthy persons within a particular population
recommended daily allowance (RDA)
42
patient requirements for measuring basal metabolic rate (BMR)
patient should be fasting, resting, and supine in a thermoneutral environment
43
topiramate causes what type of metabolic acidosis?
hyperchloremic (non-anion gap MA) due to carbonic anhydrase effect
** metformin (high anion gap)
44
metformin causes what type of metabolic acidosis?
lactic acidosis = High anion gap MA
- also Topiramate
45
how many calories in a very low calorie diet?
<800 kcal/day
46
very low calorie diets contain a predominance of what macro-nutrient?
protein
47
how do anti-obesity medications typically affect HDL, LDL, and triglycerides?
- increased HDL
- lowered LDL
- lowered TG
48
what condition causes painful lipomas on the torso and proximal extremities
adiposis dolorosa (Dercum's disease)
49
what is the mechanism behind re-feeding syndrome?
high carbohydrate intake --> insulin release --> phosphate shifts intracellularly --> low ATP --> muscle weakness and arrhythmia
50
what class of diabetes medication should be stopped when starting a ketogenic diet
SGLT-2 inhibitors, d/t increased risk of diabetic ketoacidosis
- also cause UTI's from glucose in the urine
51
what formula is preferred in calculating the resting energy expenditure in patients with obesity? what is the equation?
Mifflin-St. Jeor equation
(10 x weight) + (6.25 x height) - (5 x age) + 5
**(-161 in women)
52
what component plays the most prominent role in the Mifflin-St. Jeor equation?
weight
53
what sex has higher levels of leptin and adiponectin?
females
54
what class of diabetes medication is considered weight neutral
DPP4-inhibitors (-gliptins)
55
what is the inheritance pattern of Wilson-Turner syndrome
X-linked
56
characteristics of Wilson-Turner Syndrome
Wilson-Turner syndrome
W before X (X-linked)
Intellectual disability
Large breasts (gynecomastia)
Short stature
Obesity
Narrowed fingertips
57
food memories activate what part of the brain?
hippocampus
58
food cues such as ads and visuals activate what part of the brain?
amygdala
59
cravings, reward, and addictions are mediated by what part of the brain?
limbic system
60
weight neutral beta blocker
carvedilol
61
3 adverse reactions associated with setmelanotide
1. worsening depression or SI
2. increased sexual arousal
3. skin hyperpigmentation
62
how are testosterone levels affected by weight loss?
testosterone increases with weight loss
63
what does motivational interviewing technique "RULE" stand for
R = resist the righting reflex
U = understand your patient's motivation
L = listen to your patient
E = empower your patient
64
what dose of oral semaglutide (Rybelsus) is required for glucose improvement
7 mg or 14 mg
65
4 indications for setmelanotide
1. POMC defect
2. PCSK1 defect
3. LEPR genetic defect
4. Bardet-Biedl syndrome
66
what are the second-order neurons in the anorexigenic pathway and where are they located?
alpha-MSH and melanocortin 3 and 4, which are located in the paraventricular nucleus
67
why was lorcaserin (Belviq) taken off the market in 2020?
increased incidence of malignancy
68
why was fenfluramine taken off the market in 1997?
increased risk of valvular heart defects
69
BMI in class I obesity
BMI in class II obesity
BMI in class III obesity
BMI in class I obesity 30-34.9
BMI in class II obesity 35-39.9
BMI in class III obesity 40
70
Edmonton Obesity Staging System
Stage 0- no risk factors
Stage 1- subclinical risk factors
Stage 2- have chronic diseases
Stage 3- have end organ damage
Stage 4- life threatening disability
71
what is the most common non-inherited, non-polygenic genetic syndrome that may promote obesity?
Prader-Willi
72
what is the most common inherited, non-polygenic syndrome that may promote obesity?
melanocortin 4 receptor deficiency
73
waist circumference provides additional CV risk stratification at what BMI?
25-34.9
74
a fat restricted diet contains what % of total calories from fat?
10-30%
75
how many grams of carbohydrates are in a very low-carbohydrate diet?
<50 grams
76
carbohydrates contain how many kcal per gram?
4 kcal/gram
77
the dietary reference intake (DRI) for carbohydrates is how many grams per day?
130 grams/day
78
fats contain how many kilocalories per gram?
9 kcal/gram
79
What are the 2 essential fatty acids?
Omega 3: Alpha-linolenic acid
Omega 6: Linoleic acid
80
what is the dietary reference intake (DRI) for fat?
30 grams/day
81
types of fats which may reduce cardiovascular risk
polyunsaturated &
monounsaturated
82
omega-3 fatty acids (4 grams/day of eicosapentaenoic acid) can reduce what type of cholesterol levels?
triglycerides
83
examples of monounsaturated fats
olive, canola
84
essential amino acids
Pvt Tim hill
phenylalanine
Valine
threonine
tryptophan
Isoleucine
Methionine
histidine
isoleucine
leucine
lysine,
85
dietary reference intake (DRI) for protein
0.8 - 2.0 grams/kg/day
86
how does insulin affect fat metabolism?
insulin inhibits lipolysis and promotes lipogenesis
87
low calorie diets contain how many calories per day
1200-1800 kcal/day
88
how does restriction of dietary fat affect cholesterol?
- decrease in total cholesterol
- decrease in LDL cholesterol
89
5 A's of obesity management
Ask
Assess
Advise
Agree
Assist
90
the only pharmacotherapy with an FDA indication to treat binge-eating disorder
Lisdexamfetamine dimesylate - CNS stimulant
91
physical findings in Bulimia
- Russell sign (calluses on dorsum of hands)
- Enamel erosion of teeth
- Sialadenosis (enlargement of the salivary gland)
92
lab findings in Bulimia
- Hypokalemia (due to hypomagnesemia)
- hypochloremia
- metabolic alkalosis
- elevated amylase
93
FDA-approved pharmacotherapy for bulimia
Fluoxetine
94
pharmacotherapy used for night-eating syndrome
sertraline
topiramate
95
what differentiates night-eating syndrome from sleep-related eating disorder?
- NES: awareness of evening or noctural ingestions
- SRED: NOT aware of eating; a/w hypnotics, sedatives
96
forgetfulness of the degree of change and effort required to achieve initial weight loss success
commitment amnesia
97
goal setting should be SMART - what does this stand for
Specific
Measurable
Achievable (Realistic)
Relevant (Important to patient)
Timed
98
what drug can be used to treat antipsychotic-related weight gain?
metformin
99
anti-epileptics that are weight negative
topiramate
zonisamide
100
TCAs that is weight neutral
nortriptyline
101
orlistat increases the risk of what type of kidney stones
calcium oxalate
102
topiramate increases the risk of what type of kidney stones
calcium phosphate
103
gastric bypass surgery can increase risk of what type of kidney stones
calcium oxalate
104
insulin resistance increases risk of what type of kidney stones
uric acid
105
indications for anti-obesity medications
- BMI 30 and above
- BMI 27 with increased adiposopathic complications (T2DM, HTN, dyslipidemia)
106
adverse effect of phen-fen
primary pulmonary HTN
valvular heart disease
107
orlistat is contraindicated in what conditions
chronic malabsorption syndrome
cholestasis
108
where is it CCK produced
duodenum and jejunum (I-cells)
109
where is GIP produced
duodenum and jejunum (K-cells)
110
where is GLP1 produced
distal small bowel and colon (L-cells)
111
where is oxyntomodulin produced
distal small bowel and colon (L-cells)
112
where is PYY produced
distal small bowel, colon, and rectum (L-cells)
113
MOA of PYY
appetite suppression
delays gastric and intestinal emptying
"ileal break"
114
3 clinical features of MC4R deficiency
most common monogenic defect:
1. tall stature
2. increased bone mineral density ("big boned")
3. high insulin levels with insulin resistance
115
features and treatment of congenital leptin deficiency
No leptin at all! (most other syndromes have high leptin b/c amount of leptin correlates to fat level)
metreleptin
116
mutations in this gene lead to an adreneal crisis in neonates due to ACTH deficiency
POMC
117
This test estimates energy expenditure by measuring CO2 production and O2 consumption
indirect calorimetry
118
this test measures heat generated by an organism via an enclosed chamber
direct calorimetry
119
amount of nutrient estimate to meet the requirement of HALF of all healthy individuals in the population
estimated average requirement
120
highest intake of a nutrient that is likely to pose no risk of toxicity for almost all individuals
tolerable upper intake level (UL)
121
average daily dietary intake of a nutrient sufficient to meet the requirements of NEARLY ALL healthy persons within a particular population
recommended dietary allowance (RDA)
122
recommended intake value based on observed or experimentally determine approximates for a group of healthy persons
adequate intake (AI)
123
recommended amount an indivudal should consume for a specific nutrient
daily value (DV)
124
Most common tumor to cause hypothalamic obesity
Craniopharyngioma
125
Masses in what part of the hypothalamus lead to obesity?
VentroMedial
(Masses in the ventroMedial hypothalamus lead to More weight)
126
common amino acid deficiency in vegans
lysine
127
the study of changes caused by GENE EXPRESSION rather than the genetic code
epigenetics
128
where is vitamin B12 absorbed?
terminal ileum
129
this hormone is secreted by the F cells of the endocrine pancreas in response to food intake
pancreatic polypeptide
130
is pancreatic polypeptide anorexigenic or orexigenic?
anorexigenic
131
is pancreatic polypeptide decreased or elevated in obesity?
decreased
132
at similar BMIs, who has lower levels of leptin, males or females?
males
133
how do sleep deprivation and reduced sleep quality affect leptin levels?
decreased leptin levels --> increased appetite and reduced energy expenditure
134
genetic inheritance and features of Beckwith-Wiedemann syndrome
chromosome 11p15.5 dysregulation
"wide" = enlarged organs
tumors
135
genetic inheritance pattern of
- Cohen syndrome
- Congenital leptin deficiency
- POMC deficiency
- Bardet-Biedl syndrome
- Wilson-Turner syndrome
- MC4R deficiency
- Alstrom syndrome
- Cohen syndrome (8q22 mutation) autosomal recessive
- Congenital leptin deficiency autosomal recessive
- POMC deficiency autosomal recessive
- Bardet-Biedl syndrome autosomal recessive
- Wilson-Turner syndrome X-linked
- MC4R deficiency auto dominant or recessive
- Alstrom syndrome autosomal recessive
136
Type I muscle fiber characteristics
1. slow twitch
2. energy via oxidative metabolism (more mitochondria)
3. fatigue resistant
4. used in prolonged activities (marathon)
137
type II muscle fiber characteristics
1. fast twitch
2. energy via anaerobic glycolysis
3. fatigue susceptible
4. used in forceful activities (boxing, sprinting)
138
what gives brown adipose tissue its brown color
mitochondria
139
how does brown adipose tissue increase resting metabolic rate
utilizing glucose and FFA to increase lipolysis
140
how does brown adipose tissue serve as a warming mechanism?
uncoupling oxidative phosphorylation --> generating heat via non-shivering thermogenesis
141
most sensitive test to diagnose diabetes mellitus
oral glucose tolerance test
142
definition of apnea
respiratory pauses that last 10 or more seconds
143
diagnostic criteria for OSA
Minimum 5 episodes of apnea/hypopnea per hour
- apnea: respiratory pause > 10 s
- hypopnea: shallow breathing with O2 desat > 4%
144
how does bupropion/naltrexone aid in weight loss?
Contrave:
bupropion: stimulating cleavage of POMC --> increased alpha-MSH --> promoting anorexigenic pathway
naltrexone: blocks POMC opioid receptor; will not work without bupropion!
145
screening tests for Cushing's syndrome and features
-low dose dexamethasone suppression test
-24 hr urine free cortisol
-salivary cortisol levels
features: moon facies, buffalo hump, easy bruising
146
definition of respiratory quotient
- carb
- protein
- fat
CO2 produced/consumed O2
*measured by indirect calorimetry
respiratory quotient of carbohydrates 1 --> high intesity work-out
respiratory quotient of protein 0.8
respiratory quotient of fat 0.7 --> slow jog
147
dx and treatment of IIH/pseudotumor cerebri
Dx: LP
- 5-10% weight loss
- low sodium diet
- carbonic anhydrase inhibitors (acetazolamide, topiramate)
148
Obesity in children 2-20 categories
Health < 85%
Overweight > 85%
Obesity > 95%
- class 1: < 120% of 95%
- class 2: > 120% of 95%
- class 3: > 140% of 95%
Severe obesity > 99%
149
vitamin deficiency that presents with sore throat, cheilitis, stomatitis, glossitis, itchy eyes
Vitamin B2 (riboflavin)
150
vitamin deficiency that presents with pellagra (dermatitis, diarrhea, dementia, death)
niacin
151
consumption of large quantities of egg whites can lead to a deficiency in what B vitamin?
biotin (B7)
152
lean body mass vs. fat free mass
lbm: total body mass - non-essential adipose tissue
- essential fats remains
ffm: total body mass - total body fat
153
condition similar to binge eating disorder but presents in children <12 years old
loss of control eating disorder
154
first line treatment for loss of control eating disorder (<12 yo)
interpersonal psychotherapy
155
Blount disease
this disease involves bowing of the tibia (varus) seen in children with obesity
156
Ortho issues:
- slipped capital femoral epiphysis (SCFE)
- Blounts disease
- Perthes disease
Ortho issues:
- slipped capital femoral epiphysis: salter harris fx at the hip
- Blounts disease: tibia bowing
- Perthes disease: idiopathic avascular necorisis of femoral head
157
slipped capital femoral epiphysis
Pediatric condition caused by instability of the growth plate of the proximal femur, resulting in a Salter-Harris fracture
158
hormonal imbalance in PCOS
increased LH:FSH ratio
increased androgens
159
Rotterdam criteria
Diagnosis of PCOS (2 out of 3)
- amenorrhea/anovulatory cycles
- signs of hyperandrogenism (hirsutism, acne, alopecia, virilization, infertility)
- polycystic ovaries on US
160
Mechanism of refeeding syndrome
prolonged malnutrition --> depleted phosphate
consuming high carb loads --> insulin release --> phosphate shifts into cells
lack of phosphate for ATP --> muscle weakness & arrythmia
161
this vitamin deficiency presents with bleeding gums, petechiae, spiral/corkscrew hairs, and poor wound healing
vitamin C (scurvy)
162
what 2 organs have the highest resting metabolic rate (RMR)?
skeletal muscle and liver (20% each)
163
dietary thermogenesis comprises what percentage of daily total energy expenditure?
10%
164
physical activity comprises what percentage of daily total energy expenditure?
20%
165
STOP Bang scoring
Used for OSA
- Snoring
- Tired during day
- Observed apnea
- Pressure (BP) is elevated
- BMI >35
- Age >50 years
- Neck circumference > 40 cm
- Gender = male
166
Most weight neutral SSRI
fluoxetine
167
SHBG (sex hormone binding globulin) Correlations
- Obesity
- PCOS
- Age
- Old and skinny people have high SHBG
- Obesity, PCOS, and younger age have low SHBG
168
recommended labs to obtain in children with BMI 85th-95th percentile and no risk factors
fasting lipid panel
169
recommended labs to obtain in children with BMI 85th-95th percentile and WITH risk factors (HLD, OSA, family hx of MAFLD, pre-DM or DM)
fasting lipid panel +
AST, ALT, fasting glucose
170
recommended labs to obtain in children with BMI 95th percentile or greater
fasting lipid panel +
AST, ALT, fasting glucose +
BUN and Cr
171
primary, secondary, and tertiary prevention
primary- prevent obesity
secondary- once obese prevent complications
tertiary- once complications, mitigate them
172
minimum BMI required for lap banding
30
172
Children 5-14:
- TV-time
- sleep
- activity
- dessert
- TV time: <2 hours. No TV in room
- Sleep: at least 10 hours
- Activity: at least 1 hour
- Dessert: special occasions
173
how much fiber to consume daily to improve lipids and weight?
6 g/day in ages 6-12
12 g/day in 12 and above
174
Wenicke's encephalopathy (WE) triad
1. encephalopathy
2. ophthalmoplegia & nystagmus
3. ataxic gait
175
Korsakoff syndrome
irreversible impaired short-term memory and confabulation
176
dry beriberi
symmetric peripheral polyneuropathy
177
wet beriberi
high-output CHF
178
Wernicke's encephalopath
- what vitamin deficiency
- what is the cause/onset?
- sxs
- B1 (thiamine)
- Ususually after bari surgery. Occurs rapidly (days to weeks) comapred to other deficiencies
- ascending weakness
179
Qsymia is approved for pediatric patients of what age and BMI?
12 years and above with BMI of 95th %ile
180
MOA of topiramate in weight loss
enhances GABA activity and Na+ channels --> appetite suppression and enhanced satiety
181
MOA of phentermine in weight loss
sympathomimetic amine which stimulates the hypothalamus to release norepinephrine --> decreased appetite and food intake
182
contraindications to phentermine/topiramate
1. concurrent MAOI
2. hyperthyroidism
3. glaucoma
4. renal stones (ca phosphate 2/2 topiranate)
183
2 indications for bariatric surgery
BMI 30 with metabolic disease
or
BMI 35 without comorbidities
BMI threshold in Asian population for consideration of bariatric surgery BMI 25 + comorbidity
BMI 27.5 w/o comorbidity
184
anti-obesity medicines used in ESRD
1. orlistat
2. GLP-1
3. cellulose and citric acid hydrogel
185
all weight loss medications are permissible at what GFR?
GFR > 50 ml/min
186
What does OARS stand for in motivational interviewing?
Open-ended questions - avoid yes/no answers
Affirmations - recognize strengths
Reflection - careful listening
Summarize - recap of discussion and set plans to follow up
187
what does RULE stand for in motivational interviewing?
Resist the righting reflex
Understand your patient's motivation
Listen to your patient
Empower your patient
188
preoperative ERABS recommendations for improved surgical outcomes
- deep breathing exercises
- CPAP
- incentive spirometry
- leg exercises
- H2 blocker / PPI
- carbohydrate loading
- pre-anesthesia medication
189
intraoperative ERABS recommendations for improved surgical outcomes
- opioid-sparing multi-modal analgesia
- pulmonary recruitment maneuvers
- protective ventilation strategies
- goal-directed fluid management
- regional blocks
- anti-emetic prophylaxis
- silent bleeding detection
190
post-operative ERABS recommendations for improved surgical outcomes
- thromboprophylaxis
- early return of oral intake
- multimodal analgesia
191
recommendations for perioperative VTE treatment in bariatric surgery
use parenteral anticoagulation for the first 4 weeks before transitioning to DOAC or VKA
192
the bioavailability of DOACs are least likely to be affected by what type of bariatric surgery?
sleeve gastrectomy
193
MOA of DPP4 inhibitors (gliptins)
prevent breakdown of incretins GLP1 and GIP
194
Features of Binge Eating Disorder
Binge at least 1x/week x 3 months
Eat more rapidly then normal
No compensatory purging
195
Stages of behavioral change:
Pre-contemplation: unaware of issue or unwilling to change
Contemplation: interested in changing within the next 6 months
Preparation: willing to change in the next 30 days (planning)
Action: initiation of change (6 months)
Maintenance: continued change for >6 months
Relapse: returning to undesirable behaviors
196
recommended duration of
- moderate-intensity aerobic exercise
- vigorous-intensity aerobic exercise
moderate-intensity aerobic exercise: 150-300 minutes per week
vigorous-intensity aerobic exercise: 75-150 minutes per week
**if you don't have time for moderate than less time of vigorous may be a good solution
197
How many METs is moderate intensity?
How many METS is vigorous intensity?
How many METs is moderate intensity? 3-6 METs
How many METS is vigorous intensity? >6 METs
198
target heart rate in moderate-intensity exercise
target heart rate in vigorous-intensity exercise
target heart rate in moderate-intensity exercise 64-76% of maximum heart rate
(max heart rate = 220 - age)
target heart rate in vigorous-intensity exercise 77-93% of max heart rate
(max heart rate = 220 - age)
199
How much of the stomach is removed in a sleeve gastrectomy?
80%
199
patients with sleeve gastrectomy are most prone to what vitamin deficiency?
B12 (due to removal of parietal cells which produce intrinsic factor)
199
Mechanism of dumping syndrome
high carb loads rapidly empty into small bowel --> rapid glucose absorption --> exaggerated insulin release --> symptomatic hypoglycemia
199
how to prevent dumping syndrome
- reduce simple carbohydrates
- increase protein
- increase fiber
- small, frequent meals
200
shared traits among patients who have successfully maintained weight loss for extended periods (based on the National Weight Control Registry)
- exercise at least 1 hour daily
- eat breakfast
- watch <10 hours of TV weekly
- weigh-in at least once weekly
- low-calorie, low-fat diet
- maintain a consistent eating pattern across weekdays and weekends
200
REMS recommendations for Qsymia (phen-top)
pregnancy test before starting medication and monthly thereafter
+
effective birth control
- can be used alone: tube ligation, IUD, progestin implant, or vasectomy
- all other hormonal birth control methods require an additional barrier method
200
if starting a GLP-1, what class of medication should be discontinued, as there is no additional benefit?
DPP4 inhibitors (ex: sitagliptin)
200
how is SIBO diagnosed?
carbohydrate breath test
201
Symptoms of SIBO
- bloating
- abdominal pain
- watery diarrhea
- B12 deficiency (d/t competitive absorption with host)
- folate excess (over-synthesized by excessive bacteria)
202
treatment of sarcopenia
- adequate protein intake (1-1.5 g/kg/day)
- resistance exercise training
- adequate vitamin & mineral supplementation
202
treatment of choice for pre-pubescent children with obesity
cognitive behavioral therapy
203
nutrients that have potentially favorable effects beyond basic nutrition
functional foods
203
micronutrient deficiency that causes alopecia, anosmia, brittle nails, and chronic diarrhea
zinc
203
weight negative mood stabilizer
weight negative mood stabilizer: lamotrigine
204
nicotine products must be stopped how long before MBS?
6-8 weeks
205
every 1 lb decrease in weight corresponds to reduction of systolic and diastolic BP by how many mmHg?
1 mmHg
206
what diet is beneficial in hepatic steatosis
Mediterranean
207
what anti-obesity medications must be avoided in patients with severe liver impairment / cirrhosis
- Qsymia (phent/top)
- Contrave (bupro/naltrexon)
208
minimum age requirement for
- phentermine
- orlistat
- Qsymia
- liraglutide
- naltrexone/bupropion
- tirzapetide
phentermine 16 years
orlistat 12 years
Qsymia 12 years
liraglutide 12 years
naltrexone/bupropion 18 years
tirzapetide 18 years
209
reducing saturated fats with polyunsaturated fats has been shown by the ACC to reduce risk of CVD by what percentage?
30% (similar to statin use)
210
a form of omega-3 polyunsaturated fatty acid that reduces the risk of fatal CAD and is recommended by the AHA
alpha-linoleic acid
211
dietary sources of alpha-linoleic acid
- fatty fish: cod, sardines, tuna, salmon, herrring, trout
- avocado
- vegetable oil, flaxseed oil
- walnuts
- soy
- spinach, kale
212
initial treatment of post-gastric bypass hypoglycemia
low carb, mixed diet
213
this complex disaccharide delays the digestion of carbohydrates, resulting in delayed/diminished insulin release
acarbose
214
this somatostatin analog is a potent insulin inhibitor
octreotide
215
this class of medications acts directly on the beta cells to inhibit glucose-dependent insulin release
calcium-channel blockers
216
short term weight loss devices
Gastric balloon (<6 months)
TransPyloric shuttle (<12 months)
217
FITTE exercise prescription
Frequency
Intensity
Time
Type
Enjoyment
218
most common side effects of phentermine
- insomnia
- constipation
- xerostomia
- tachycardia
219
maximum dose of Qsymia
Phen/Top
15/92 mg daily
220
minimum daily vitamin and mineral intake after MBS
- 2 adult multivitamins containing folic acid, thiamine, and B12
- vitamin D: 3000 IU daily
- calcium: 1200 - 2400 mg, varies w/surgery)
- iron (18 mg in men, 60 mg in menstruating females)
221
what formulation of metformin is recommended after bariatric surgery
immediate release
222
when to consider DXA scan after bariatric surgery
2 years post-op
223
which bariatric surgery is associated with significant diabetes remission?
SADI-S
224
which bariatric surgery provides the most pronounced weight loss, and is effective for high BMIs?
BPD/DS
225
diabetes medication that increases total body weight by increasing water retention
pioglitazone
226
insulinoma characteristics
- both fasting and post-prandial hypoglycemia
- elevated fasting C-peptide
227
first line antihypertensives to use in patients with obesity
RAS inhibitors (ACEi or ARB)
228
effect of low carb diet on lipid panel
- increased HDL
- decreased TG
- increased LDL
229
effect of low fat diet on lipid panel
decreased LDL
230
Moa and side effects of Plenity
Moa: oral hydrogel capsule
- abdominal pain
- diarrhea
- altered absorption of other medications
231
MOA and BMI of Plenity
BMI 25-40
MOA of Plenity contents form a 3D matrix within the stomach & small intestines that occupies volume --> increased satiety
232
prevention of cholelithiasis from rapid weight loss after surgery
ursodeoxycholic acid
233
black box warning for Contrave
risk of suicide in young adults
234
why are patients advised to follow a low-cal high protein diet a few weeks prior to BMS?
to promote a reduction in liver size --> improves laparoscopic visualization of organs and decreases mechanical injury
235
Cancers not associated with obesity
skin, oral, lung, lymph nodes
236
setmelanotide is approved for what age?
6 years and above
237
in Motivational interviewing, what does DARN represent?
Desire
Ability
Reasons
Need to change
*listen for these when EVOKING the patient's interest and motivation to change
238
patients using a TransPyloric Shuttle should be started on what medication to reduce the risk of gastroesophageal tissue injuries?
PPI
239
TransPyloric Shuttle is approved for what BMI?
duration of use for TransPyloric Shuttle
mechanism of action of TransPyloric Shuttle
- BMI 30 with an obesity comorbidity
- 12 months max
- removable gastric bulb which reduces the gastric transit of food
240
weight NEUTRAL and weight NEGATIVE migraine medications
Neutral:
- NSAIDs
- Triptans
- CGRP Antagonists (Erenumab, Rimegepant)
- Botox
Negative:
- Topiramate
- Zonisamide
241
weight POSITIVE migraine medications
- valproic acid
- propranolol, atenolol
- amitriptyline
242
most common cause of insufficient weight loss or weight regain after bariatric surgery
behavioral-mediated
- dietary indiscretion
- non-adherence with caloric restriction
- lack of exercise
- undiagnosed eating disorders
243
Minimum weight loss recommended for metabolic benefits
At least 5-10%
244
black box warning for metformin and RFs
lactic acidosis
risk factors:
- age >65
- contrast studies
- renal failure
- hypoxia
- significant alcohol use
245
MOA of metformin (3)
1. decreases hepatic glucose production
2. decreases intestinal glucose absorption
3. increases insulin sensitivity
246
clinical features of Prader-Willi syndrome
Paternal chromosome 15 deletion
Reduced tone, reduced cry, reduced height
Almond-shaped eyes
Developmental delay
Ravenous eating
247
clinical features of Bardet-Biedl syndrome
BBS gene mutation - cilia gene mutation
Autosomal Recessive
Renal & Retinal disorders
Developmental delay
Extra fingers & toes (polydactyly)
Tiny gonads (hypogonadism)
248
weight POSITIVE birth control
weight NEUTRAL birth control
weight POSITIVE birth control
- medroxyprogesterone (Depo-Provera)
weight NEUTRAL birth control
- IUD
- barrier methods
- progesterone-only pills
249
potential complication of eliminating fat from diet
gallstones
249
complication of bariatric surgery that presents with recalcitrant epigastric pain and has non-specific endoscopic and histologic findings
bile acid gastritis
*more common in one-anastomosis gastric bypass / mini-gastric bypass
250
metformin reduces risk of progression to diabetes by what percentage
- when should it be prescribed
31%
- pre-DM (a1c < 6.4%) especially if < 60 yo
251
short-acting sympathetic amines for weight loss and clinical use
- diethylpropion (half life of 4-6 hours)
- benzphetamine (4-6 hours)
- phendimetrazine (3-7 hours)
**can be used as an adjunct to phentermine in the afternoon
252
Moa and contraindications to pramlintide
Amylin analogue
Gastroparesis, hypoglycemia unawareness
252
this medication can make soda undesirable
topiramate
253
Amylin: production, MOA, s/e
- beta cells of the pancreas
- released with insulin; inhibits glucagon, inhibits gastric emptying, increases satiety
- s/e: can cause hypoglycemia
254
when a person is unaware of deep-rooted views, often affecting how they act
implicit bias
254
before starting an exercise program, the ACC recommends performing a stress EKG in patients who meet one the following criteria:
1. multiple cardiac risk factors
2. men >40 who plan to start VIGOROUS exercise
3. women >50 who plan to start VIGOROUS exercise
255
when to start using BMI in children?
2 years old
256
how to assess weight status in children <2 years of age
WHO - weight for length growth chart
257
which growth chart to use for children aged 2 and above?
CDC growth chart
258
the wear and tear on the body which accumulates as an individual is exposed to repeated or chronic stress
allostatic load
259
BP should be checked annually in overweight and obese children starting at what age
3 years
260
foundational therapies in obesity management of children
- intensive healthy, behavior and lifestyle therapy (ILT)
- very time intensive
- not motivational interviewing or meds
261
Age of approval:
- Qsymia
- phentermine
- liraglutide
- orlistat
- Qsymia:12 years
- phentermine: 16 years
- liraglutide: 12 years
- orlistat: 12 years
262
management of infant with obesity (0-24 months)
- exclusive breastfeeding for 6-12 months
- delay complementary foods until 6 months
263
useful add-on therapy for psychotropic-induced weight gain
metformin
topiramate
amantadine
264
current ADA guidelines recommend screening for T2DM in all asymptomatic children aged 10 and above who are overweight and have at least one of the following risk factors:
- maternal GDM during child's gestation
- family hx of T2DM in 1st or 2nd degree relatives
- high risk ethnic group
- signs of insulin resistance
265
predominant pattern of dyslipidemia in children
elevated TG
normal to mildly elevated LDL
low HDL
266
fat mass disease
this results in pathologic mechanical and physical forces leading to adverse clinical outcomes (OSA, orthopedic problems)
(vs. Sick fat disease- metabolic/hormonal)
267
sick fat disease (adiposopathy)
this results in pathologic endocrine and immune responses that promote metabolic disease (DM, HTN, HLD)
(vs. fat mass disease)
268
anatomic adiposopathic changes with obesity
- adipocyte hypertrophy
- adipose tissue expansion
- increased energy storage in multiple fat depots
- increased fat deposition in body organs
269
functional adiposopathic changes with obesity
- adipose hypoxia
- increased reactive oxygen species
- extracellular matrix abnormalities
- intra-organelle dysfunction
- neurological changes
- immunopathic/endocrinopathic responses
270
how are glucose and galactose absorbed?
how is fructose absorbed?
- glucose and galactose: active transport via SGLT-1
- fructose: Facilitated diffusion via GLUT 5
271
satiation vs. satiety
feeling of fullness within a meal satiation
feeling of fullness between meals satiety
272
distribution of consumed energy to specific tissues
caloric partitioning
273
how does weight loss affect energy expenditure?
- decreased resting energy expenditure (due to loss of body tissue)
- adaptive thermogenesis (reduction in RMR exceeds that predicted by loss of body tissue)
- greater muscle efficiency (less energy expenditure with physical activity) --> may not loose as much weight after exercise
*all can lead to weight plateau / regain
274
chemotherapeutic agents associated with weight gain
- tamoxifen
- cyclophosphamide
- methotrexate
- 5-FU
- aromatase inhibitors
275
hypnotics that may increase body weight
- diphenhydramine
- zolpidem
276
dosage of liraglutide for treatment of obesity
dosage of semaglutide for treatment of obesity
dosage of liraglutide for treatment of obesity 3 mg/day
dosage of semaglutide for treatment of obesity 2.4 mg weekly
277
Contrave should not be taken with what type of food
high fat food
278
what medications may test positive for amphetamines on drug screens?
- amphetamine derivatives
- phentermine
- bupropion
- fluoxetine
- metformin
279
this AOM may potentiate hypokalemia when used with non-potassium sparing diuretics
Qsymia
280
potential drug interactions with orlistat
- cyclosporine*
- ADEK vitamins
- levothyroxine*
- warfarin (due to decreased vitamin K)
*take at least 4 hours apart from Orlistat
281
why is phentermine contraindicated within 14 days of MAOI use?
increased risk of hypertensive crisis
282
GI hormones secreted by the L cells in the ileum & colon
GLP-1
GLP-2
Oxyntomodulin
PYY
283
recommended daily water intake after bariatric surgery?
64 oz
284
AOMs contraindicated in glaucoma due to their ability to increase IOP
1. phentermine
2. topiramate
3. bupropion
285
recommended rate of weight loss in children 12 and older with BMI 95-98 percentile
2 lbs per week OR max of 8 lbs in 4 weeks
286
what is the FIRST step in evaluating IIH
1. fundoscopy. Check of papilledema
2. If presents --> brain imaging
3. lumbar puncture
287
The thermogenic effect of food (TEF) is highest for which macronutrient?
protein
288
this class of medication can often cause transient influenza-like symptoms such as severe musculoskeletal pain, fever, headache, malaise, and fatigue, sometimes accompanied by nausea, vomiting, and diarrhea.
bisphosphonates
289
what is the best test for a monogenic obesity disorder?
Next generation sequencing test for genes in the leptin-melanocortin pathway
290
what hormone is responsible for lowering of blood glucose immediately following bariatric surgery?
increased GLP-1
291
what GI hormones INCREASE after weight loss?
1. ghrelin (growth hormone related peptide)
2. Gastric inhibitory peptide
3. pancreatic polypeptide
292
what GI hormones DECREASE after weight loss?
1. Leptin
2. PYY
3. CCK
293
Most common deficiency after gastric bypass
iron deficiency
294
there is an increased incidence of what substance use disorder after gastric bypass surgery?
alcohol use disorder
- accelerated absorption
- longer time to alcohol elimination
295
Cons of Bioelectrical Impedance Analysis
- hydration dependent (pt should be euvolemic)
- cannot be used w/electrical cardiac devices
296
gold standard of body fat measurement
DEXA
297
cons of DXA
may not accommodate those with extreme BMI
298
most accurate test to determine body fat composition at the molecular level
isotope dilution hydrometry
299
clinical features of body dysmorphic disorder
- preoccupation with a flaw
- compulsive behaviors (related to OCD)
300
clinical features in Kwashiorkor
- anasarca with ascites
- apathetic
- stripes in hair (flag sign)
301
people who are leaner have higher levels of what gut bacteria
bacteroides
[itty Bitty Bacteroides]
302
People who are obese have higher levels of what gut bacteria
firmicutes
[Fat Firmicutes]
303
anorexic hormone secreted by the K-cells which has an insulin incretin effect and slows gastrric emptying
glucose-dependent insulinotropic peptide (GIP)
304
FDA-approved AOM in children
6 yrs + : setmelanotide
12 yrs + : orlistat, Qsymia, liraglutide, semaglutide
16 yrs +: phentermine
NOT approved: Contrave
305
supplements that increase energy expenditure
- Yerba mate
- ephedra
- guarana
- Yohimbe
- country mallow
- bitter orange
306
how do low carb diets affect cholesterol levels?
DECREASE triglycerides
INCREASE HDL, LDL, and TOTAL
307
in low-energy sustainable exercise, what is the expected RQ?
in high-energy exercise, what is the expected RQ?
in low-energy sustainable exercise, what is the expected RQ? 0.7 (fats being burned)
in high-energy exercise, what is the expected RQ? 1 (carbs being burned)
308
NHANES (National Health and Nutrition Examination Survey)
- in-person weighing
- smaller cohort
- more accurate than BRFSS survey
309
BRFSS (Behavioral Risk Factor Surveillance System)
- self-reported weight (less accurate as pts tend to under-report weight)
310
clinical manifestations of copper deficiency
- macrocytic anemia
- neutropenia
- myeloneuropathy (ataxia, spasticity, weakness)
**mimics b12 deficiencyf
311
where is adiponectin produced and what does it do?
white adipose tissue
enhances insulin sensitivity, decreases gluconeogenesis
312
contraindications to metformin
eGFR < 30, metabolic acidosis
313
where are the 2nd order neurons in the orexigenic pathway located?
lateral hypothalamus
314
Where is GIP produced?
Where is cholecystokinin produced?
Where is GIP produced? K cells (duodenum, jejunum)
Where is cholecystokinin produced? I cells (duodenum, jejunum)
315
what is the most prevalent vitamin deficiency in those with obesity?
vitamin D
316
which malabsorptive bariatric surgery has the shortest common channel?
DS
317
benefits of oral nutrition with carbohydrates up to 2 hours before bariatric surgery?
- decreased insulin resistance
- decreased protein catabolism
- reduce hospital LOS
- faster return of bowel function
318
what two states have the highest rates of obesity in the US?
mississippi
virginia
319
Orexi pathway
Anorexi pathway
Orexi: NPY/AgRP (arc n) --> Orexin (lateral HT) --> MCH/Y1/Y5
Anorexi: POMC/CART (arc n) --> a-MSH (PVN) --> MC3/4
320
Prevalence of obesity in children
20%
321
Lymphedema vs. Lipedema
Lymphedma: pitting edema; +Stemmer's; foot involves
Lipedema: minimal pitting; +cuff sign; foot spared
322
How does fat effect thyroid hormones
Compensatory hyperthyroid: leptin stimulates TSH to increase T3/T4
323
Alstrom syndrome characteristics
Intellectual disability
Dilated cardiomyopathy
Insulin resistance
Hearing impairment
324
Features of fragile x syndrome
X-linked, large ears and long face
Strabismus
325
Virus associated with obesity
Adenovirus 36
326
Definition of Calorie
- deficit require for weight loss
1 Calorie = 1000 calories = 1kcal = amount of heat to raise temp of 1 g of water by 1C
- at least 500 kcal deficit require for weight loss
327
How does calcium effect weight
Increases lipolysis, decrease lipogenesis
328
Characteristic features of congenital disorders
- Prader-Willi
- Beckwith-Wiedemann
- Albright Hereditary Dystrophy
- Bardet-Biedl
- Angelman
- fragile x syndrome
- Borgeson-Forssman-Lehman
- Prader-Willi: almond eyes, ravenous eating
- Beckwith-Wiedemann: HSM, macroglossia
- Albright Hereditary Dystrophy: shortened MC's, psudo-HypoPTH
- Bardet-Biedl: polydactyl, renal/retinal abnormalities
- Angelman: happy demeaner, seizures
- fragile x syndrome: longs ears/face, Strabismus
- Borgeson-Forssman-Lehman: large ear lobs, seizures
329
Most likely nutritional deficiecies with vegetarian diet
1. B12
2. Vitamin D
3. Omega-3
330
Most specific enzyme for fatty liver disease
ALT
331
B Vitamin Def characteristics
B1
B3
B9
B12
B1- Thiamine: wet and dry beri-beri
B3- Niacin: pellagra (drh, dementia, derm's)
B9- Folate: macrocytic anemia
B12- Cyanocobalamin: macrocytic anemia, glossitis
332
Skin findings of insulin resistance
- Acanthosis
- Skin tags
333
Contraindications to bupropion
1. Eating disorders
2. Epilepsy
3. Anything that decreases seizure threshold
4. Hypertension (uncontrolled)
**Black box warning for suicidal ideation
334
How much weight should you gain in preggo?
BMI< 25: 25-35 lbs
BMI >25: 15-25 lbs
BMI > 30: 11-20 lbs
335
TV time and ages
0-2: none
2-4: 1 hour
> 4: < 2 hours
336
Best AOMs for patients in kidney failure
1. GLP1 agonists
2. Orlistat
3. Hydrogels
337
Treatment of PCOS
1. Lifestyle changes
2. OCPs (1st line)
3. Metformin
4. Spironolactone
338
Micronutrient deficiencies:
- Vitamin A
- Vitamin D
- Vitamin E
- Vitamin K
- Selenium
- Zinc
- Copper
- Biotin
Micronutrient deficiencies:
- Vitamin A: night blindness, hyperkeratosis
- Vitamin D: hypoCa, 2nd hyperPTH
- Vitamin E: hemolytic anemia
- Vitamin K: bleeding/bruising
- Selenium: cardiomyopathy
- Zinc: alopecia, skin issues
- Copper: anemia, wound healing
- Biotin: alopecia, seborrheic dermatitis
339
AOMs to avoid with liver impairment
- Phentermine/Topiramate
- Naltrexone/Bupropion
**OK for Childs A. Reduce dose for Childs B. C/i in Childs C
340
FDA approved AOMs for long terms use
1. Lorcaserin (removed from the market)
2. Phentermine/topiramate ER
341
Management of DM meds after weight. loss surgery
- Keep blood glu 140-180
- change metformin to immediate release
- stop insulin secretagogues, SGLTL2 inhibitors, and TZDs
- can continue glp1s
342
BB and CCB effect on weight
BB: increase adiposity; carvedilol is most weight neutral
CCB: increase constipatio and interstitial edema
343
Electrolyte changes from ketogenic diet
hyponatremia and hypokalemia
2/2 diuretic effect
344
Low fat vs. low carb diet
Low fat: improves LDL
Low carb: improves HDL and TG
345
Weight negative DM meds
1. GLP1 agonist
2. SGLT2 inhibitors
3. Biguanides
4. Amylin analogues
**NOT DPP4
346
Weight positve DM meds
1. Insulin
2. TZD
3. Meglitinides
4. SU's
347
Pulmer Vinson Syndrome
Chronic iron def after RYGB
Can cause: microcytic anemia, esophogeal webs
348
MI principle used to help patient identify area of ambivalence or struggle
Focusing
349
MI principle used to discover patient's motivation to change
Evoking
350
Major side effect of green tea extract
hepatotoxicity
351
Levothyroxine dosing after bariatric surgery
- May need to increase dose, especially after any malabsorptive procedure (bypass)
352
Ffm vs. lbm
Ffm: total body weight - all fat weight
Lbm: includes fat from marrow, bones, and organs
