Case 16 - SIMPLE - 45 yo overweight Flashcards
Risks of obesity
- increase insulin resistance, increases LDL and Triglycerides, decreases HDL
- is a risk factor of HTN, T2Dm, CHD, stroke, PVD, CHF, A fib, gout, OA, back pain, GERD
- patients with BMI >40 have higher death rates from cancers including lymphoma, myeloma, and gi cancers
Coronary heart disease risk assessment
Risk factors: tobacco, HTN, HDL <40, high LDL, fam hx of premature CHD, age
Risk equivalents: diabetes, symptomatic carotid artery disease, peripheral artery disease, AAA
Dyslipidemia etiologies
- familial
- cauesd by diabetes, liver disease, neprotic syndrome, hypothyroidism, hepatitis, thiazide diuretics, beta blockers, oral estrogens
Metabolic syndrome definition
Any three of the following:
- fasting glucose >100 mg/dl
- BP >130/85
- trigylcerides >150
- HDL < 40 for men 40 for men >35 for women)
Pathophysiology of metabolic syndrome
- insulin resistance is underlying mechanism
Complications of metabolic syndrome
CHD, diabetes, hepatic steatosis, hepatocellular carcinoma, cholangiocarcinoma, CKD, OSA, gout
Treatment of metabolic syndrome
1st line- aggressive lifestyle management
- meds offered if lifestyle management not successful
History for pt with metabolic syndrome
- dietary history
- weight history
- review of physical activity - determine caloric req.
- social history (tobacco, alcohol, other subs)
- psychosocial stress
- sleep history - snoring, arousal, daytime somnolence
Physical exam for CHD
- increased waist circumference (>40 M, <35 F)
- increased waist to hip ratio
Signs of hypercholesterolemia
- xanthelasma on eyelids
- xanthomas on extensor tendons
Signs of vascular disease on exam
carotid bruit, diminished peripheral pulses, HTN, increased abdominal aortic size
Signs of Cushing’s syndrome/cortisol excess
striae, hyperpigmentation, moon facies, buffalo hump, easy bruising, muscle weakness
Signs of hypothyroidism
fatigue, cold intolerance, constipation, depressed tendon reflexes
Calculating basal metabolic rate
Multiply body weight times 10 and multiply that number by an activity factor:
- 1.3 if sedentary
- 1.5 for moderate activity
- 1.7 for heavy activity
- 1.9 for intense activity
- to lose weight, caloric intake < BMR + additional activities
Behavioral counseling, 5 As
Assess dietary practices Advise patient to change dietary practices Agree with patient on goals Assist in changing dietary practices Arrange follow-up
Studies for metabolic syndrome
- fasting lipid profile, LDL= TC - (HDL+TG/5)
- National cholesterol education program screening recommendations: all adults over 20, fasting lipids every 5 years
- USPTF recommends screening in men >35, women >45 and younger adults with CHD risk factors
Diabetes screening cutoffs
- fasting glucose of >126 or random glucose >200 indicates diabetes
- fasting glucose 100-125 indicates pre-diabetes
- hemoglobin A1C 5.7-6.4% is prediabetes
- HbA1C >6.5 is diagnostic of diabetes
Management of LDL dyslipidemia
- therapeutic lifestyle changes
- low fat, low cholesterol diet
- increased physical activity
- medications: statins, bile acid sequestrants, nicotinic acid (niacin), fibric acid, ezetimibe (prevents cholesterol absorption)
- check lipids 6 weeks after initiating therapy, and then every 6-12 months afterwards
Statin side effects
Hepatic dysfunction and myopathy
HDL dyslipidemia treatment
- lifestyle interventions
Medication for weight loss
- orlistat - gi lipase inhibitor - decreases fat absorption - only medication approved by FDA for long term treatment of obesity
- phentermine - modest weight loss but stimulant effects
- OTC weight loss supplements - not regulated by FDA
