Exam #3 Flashcards

1
Q

What is the DGA?

A

Dietary Guidelines for American
revised every 5 years. Latest one came out in 2010
science-based divided into chapters

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2
Q

According to the 2010 DGA, what foods should Americans reduce?

A
sodium
fats
calories from solid fats and added sugars
refined grains
alcohol
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3
Q

What are the DGA guidelines for sodium

A

reduce intake to

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4
Q

What are the DGA guidelines for fat intake?

A

Saturated fatty acids

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5
Q

According to the DGA guidelines, what foods should we increase?

A
Vegetables
fruits
whole grains
milk
seafood (in place of some meat/poultry)
oils
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6
Q

According to the DGA guidelines, what are the nutrients of public health concern?

A

potassium
fiber
calcium
vitamin D

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7
Q

What are the goals of the DGA?

A

Promote health
reduce the risk of chronic diseases
reduce the prevalence of overweight and obesity
Two new overarching concepts:
- maintain calorie balance over time to achieve and sustain healthy weight
- focus on consuming nutrient dense foods and beverages

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8
Q

What are the 5 basic food groups in my plate?

A
fruits
vegetables
protein
grain 
dairy
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9
Q

What is 1 serving of fruits or vegetables?

A
1 c. raw or cooked vegetables
1 c. vegetable or 100% fruit juice
2 c. raw leafy greens
1 apple
1/4 c. dried fruit
8 large strawberries
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10
Q

What is nutrient dense?

A

foods and beverages that provide vitamins, minerals, and other beneficial substances & relatively few calories w/out solid fats in the food or added to it, added sugars, added refined starches, added sodium
examples: all vegetables, fruits, whole grains, seafood, eggs, beans and peas, unsalted nuts & seeds, fat-free & low-fat dairy, & lean meats & poultry

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11
Q

What is the key to managing weight?

A

calorie balance

no optimal proportion of macronutrients, just that calories in = calories out

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12
Q

What are the functions and classes of macronutrients?

A

provide energy
promote growth and development
regulate body functions
- carbohydrates: primary source of calories for the brain, involved in construction of organ and nerve cells. Fiber ( keeps bowel functioning properly
- fats: required for formation of hormones, slowest source of energy but most efficient
- proteins: required for growth, especially by children, teenagers and pregnant women

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13
Q

What are the suggested percentages of daily caloric intake for macronutrients?

A

For kids 4-18:
45-65% CHOs, 4 cal/g
12-35% fats, 9 cal/g
10-30% protein, 4 cal/g

For adults:
45-65% CHOs
20-35% fats
10-35% proteins

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14
Q

how many calories does 1 pound of body fat store

A

3500 calories

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15
Q

How do you determine your daily calorie goal to lose weight?

A

4 options:

  1. 500 calories/day less than current intake
  2. current weight X 12 minus 500
  3. use estimation tables or calculators
  4. use guideline/organization standard recommendations
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16
Q

What are the principles for promoting calorie balance?

A
  • Monitor food & beverage intake, activity & body weight (very effective)
  • focus on total number of calories consumed
  • reduce portion sizes
  • when eating out, make better choices (smaller portions or lower calorie options)
  • limit screen time (reducing sedentary time)
  • go to www.calorieking.com
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17
Q

How are whole grains different from refined grains

A

whole grains contain all parts of naturally occurring nutrients of the entire grain: bran (outer shell - contains antioxidants, B vitamins & fiber), endosperm (inner portion - contains CHOs, proteins & some b vitamins - largest part)
germ (nutrient rich inner for - contains B vitamins, vitamin E, unsaturated fat & antioxidants)
refined grains are milled to remove bran and germ - removes dietary fiber, iron & many B vitamins - loses 25% of protein & 17 key nutrients
most refined grains are enriched, but fiber is not added back in
look for “whole” or “100& whole grain”

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18
Q

What is 1 serving of grain?

A

1 slice of bread, 1c. cold cereal, 1/2 c. rice or pasta

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19
Q

What are the benefits of whole grains?

A

help you feel full between meals
associated with lower BMI
reduced risk of obesity & weight gain
may reduce risk of CV disease
add flavor & texture to food
associated w/reduced incidence of diabetes

20
Q

What are SMART goals?

A
S - specific
M - measurable
A - achievable
R - relevant
T - time bound

center goals around behaviors
no more than 2-3 goals at first

21
Q

What are the clinical measures for obesity

A
BMI 25-29.9 kg/m2 = overweight
BMI >/= 30-35 kg/m2 = class 1 obese
>/= 35-40 kg/m2 = class 2 obese
>/= 40 kg/m2 = class 3 obese - extreme obesity
22
Q

What are the comorbidities associated with obesity?

A
  • Cardiovascular: HTN, congestive heart failure, coronary artery disease, stroke
  • pulmonary: obstructive airway disease, sleep apnea, pulmonary hypertension
  • metabolic: hypercholesterolemia, hypertriglyceridemia, low serum HDL, diabetes mellitus, hyperinsulinemia
  • dermatologic: stretch marks, hirsutism, skin tags
  • gastrointestinal: esophageal reflux, hiatus hernia
  • musculoskeletal: degenerative joint disease
  • psychological: eating disorders, depression, social stigma
  • neoplasm: breast cancer, colon cancer
23
Q

What is the obesity paradox?

A

data suggests that those who are obese have a survival advantage - especially after 65 y.o.
obese vs. “normal weight obesity”
normal body weight, low lean muscle mass (sarcopenic)
–> an active obese person is healthier than a sedentary skinny person
obese fit people had lower mortality than sedentary people of any weight
80% of all glucose goes into muscle. You need to move your muscles to control sugars

24
Q

How is fat distribution related to mortality?

A

central (visceral) fat is related to increased cardiovascular risk
Gynecoid (gluteofemoral) pear shaped fat is associated with lower risk of mortality - mainly subcutaneous fat

25
Q

What do adipokines have to do with anything?

A

they are expressed by macrophages & by adipocytes
play multiple roles, including inflammation, cell to cell signaling, pro-coagulation & traditional hormonal functions
MANY of them have to do with inflammation
abdominal fat has a much higher metabolic profile - more metabolically active - than subQ fat
Leptin hormone regulates feeding/fat balance - mouse with leptin deficiency is obese & hyperphagia (always hungry) - may be key in fighting obesity?

26
Q

What is the etiology of obesity?

A

environmental, genetic, physiologic
sedentary behavior
thrifty gene theory (advantage to store fat efficiently before industrialization)
sitting is the new smoking

27
Q

Food regulation signaling

A

Lots of different hormones & signaling, reward centers, behaviors - hard to control
body likes to maintain homeostasis - so when you lose weight, it’s hard to keep it off
target 5% weight loss and then stay there for a month or so to help body reset
do this over a series of times - evidence shows this is more likely to be successful at long term weight loss than losing a whole bunch at once

28
Q

How much weight do you have to lose to see any health benefit?

A

3-5%
evidence of improved blood pressure
improved lipid profile
improved insulin sensitivity, glucose tolerance
possibly most effective before onset of disease
Best programs incorporate:
dietary adjustments AND
physical activity - raises your metabolic rate
+/- pharmacologic therapy

29
Q

What are the BMI thresholds for pharmacotherapy or surgery?

A

BMI >/= 30 or
BMI >/= 27 with comorbidity - pharmacotherapy as an adjunct to comprehensive lifestyle intervention

BMI >/= 40 or BMI >/= 35 with comorbility - bariatric surgery option

30
Q

What is the average weight loss with bariatric surgery?

A

20-35% from baseline after 2-3 years
16% after 10 yrs.
(drug therapy target is just 5% weight loss)

31
Q

What are the most common types of bariatric surgeries?

A

Gastric banding and Roux-en-Y

less common are biliopancreatic diversion and sleeve gastrectomy

32
Q

What is laparoscopic adjustable gastric banding?

A

Inflatable silicon device placed laparoscopically around top portion of stomach
band is adjusted by saline solution via small access point (can take 3-5 adjustments)
optimal restriction targeted to allow food to pass slowly while restricting food volume/hunger
no bypassing of stomach or intestines
~66 lbs wt loss at 1 yr, 77 lbs @ 3 yrs
30-50% excess weight loss
if band is too tight, you throw up all the time. You also throw up if you over-eat

33
Q

What are the pros and cons of gastric banding?

A

Chronic disease remission: improvements in blood pressure, cholesterol profile, the more weight that is lost, the greater the chances of disease remission

risks: 0.4% mortality w/procedure
DVT formation & wound infection uncommon
Risk of band slipping, eroding, failing
$12,000-$36,000 for surgery - not always covered by insurance
food intolerance

34
Q

What is Roux-en-Y gastric bypass?

A

bypasses most of the stomach & some of the duodenum - reattaching the stomach further down the intestines & making stomach smaller
60-70% excess weight loss
small pouch created as stomach
unidirectional intestine prevents bile from spilling back into pouch
mal absorptive as well as restrictive
lose nutrients, too

35
Q

pros and cons of Roux-en-Y

A

~$25,000 for procedure not including complications & cost of extended hospital stay
cosmetic surgery sometimes needed to remove extra skin

T2DM remission occurs before weight loss
30-35% of patients are in remission before hospital discharge. ~83% remission rate overall
greatest success in younger, shorter disease duration

36
Q

What are some unresolved issues regarding bariatric surgery?

A
  • Gallstone formation and cholecystitis (inflammation of the gall bladder) - related to surgery and weight loss
    present in about 30% of patients at 6 mos.
    prevented with ursodiol, but poorly tolerated
  • Food intolerance: significant meat & protein intolerance. Vomiting can occur weekly or even daily
  • Nutrient deficiency: iron, B12, folate, riboflavin, niacin, thiamin, calcium, vitamin D, zinc, Vitamin A, vitamin C –> absorption enhanced by gastric acid
  • duodenum essential for nutrient absorption: proteins, fats, carbohydrates, calcium, magnesium, trace vitamins & elements
    about 30% of patients have nutrient deficiency even when adherent to vitamin regimen
37
Q

What should patient expect 3-6 months after bariatric surgery?

A

anorexia, forgetting to eat or drink
initially struggling to get fluids in
mild-moderate nausea
finding water “heavy”
dysgeusia (funny/metallic taste at first)
finding things taste too sweet
disliking many protein supplements they previously loved
finding vitamins’ taste chalky and/or awful
these people are often dehydrated

38
Q

What are some bariatric surgery considerations?

A

considering expanding coverage to all “at risk” with BMI > 30 kg/m2
~18 million T2DM patients in US
~50% have a BMI > 30 kg/m2

nutrient replacement is suboptimal
36% non-compliance rate
even among those who comply 13% are deficient in folate
30% deficient in B12 and iron
–> big role for pharmacists to follow up with 9 million people

39
Q

What is the gastric sleeve?

A

lines the upper duodenum
blocks all absorption (does the same thing as Roux-en-Y
put in through the mouth
reversible
A1C reduction of > 2.4% at 24 weeks (best drugs drop A1C at around 1.5%)

40
Q

What are the two outcomes FDA wants to see from obesity trials?

A

Mean changes: difference in mean % loss from baseline between active drug & placebo (average % weight loss)

Categorical changes: proportion of subjects that lose at least 5% of their body weight between active drug & placebo

all pharmacologic obesity drugs are approved as an ADJUNCT to lifestyle changes
if no response seen in the first 3 months, discontinue use.

41
Q

Phentermine

Diethylpropion

A

MOA: reduces food intake: sympathomimetic amine
Effect on weight: 3-3.6 kg at 6 months
SE: HA, insomnia, irritability, palpatations, nervousness

42
Q

Orlistat

A

(Xenical, Alli)
MOA: prevents dietary fat absorption ~ 30%: reversible GI lipase inhibitor
Effect on weight: 2.59 kg at 6 mos. 2.89 kg at 1 yr
approved for long term (> 12 mos) obesity mgmt.
some evidence of LDL-C, BP & glucose improvements
SE: diarrhea, flatulence, bloating, abdominal pain, dyspepsia, oily leaky stools, decreased fat soluble vitamin absorption (ADEK)
Rx (120 mg) and OTC (60mg) TID
retrains you how to eat

43
Q

Locaserin

A

(Belviq)
MOA: selective serotonin 2C receptor agonist in the hypothalamus. Decreases food consumption, promotes satiety
approved for chronic weight mgmt in adults
Effect on weight: 5.6 kg at 1 yr
SE: primarily CNS: HA, dizziness, nausea. Dry mouth & constipation less common. Hypoglycemia in diabetes pts, priapism in men
Pregnancy category X
malignancy in rats at very high doses
abuse of drug produces euphoric high similar to zolpidem, ketamine = CIV
use with caution : pts with valvular heart disease
extensively metabolized by the liver: CYP2D6 inhibitor
dosed 10 mg bid
discontinue use if 5% wt loss not achieved at 3 mos.
$239.40 for 60 tablets

44
Q

Phentermine/ topiramate CR

A

(Qsymia)
MOA: reduce food intake, promote satiety, possible increased metabolic rate. Exact moa unknown
approved for chronic weight mgmt for adults
Effect on weight: 8-10 kg at 1 yr
SE: dry mouth, paraesthesia (prickling, tingling, burning in hands, legs, arms or feet), increased resting HR, dizziness, insomnia, constipation, suicidal thoughts/actions, eye/vision problems (decreased vision acuity, increased IOP)
dosing: taper both going on & going off
2 week intervals:
3.75mg/23mg –> 7.5/46mg
11.25/69mg –> 15mg/92 mg
QD
CI: pg - negative pg tests monthly. REMS monitoring due to congenital malformations, glaucoma, hyperthyroidism, concomitant use of MAO inhibitors
$239.40 for #30 15mg/92mg tablets

45
Q

Naltexone CR/ wellbutrin CR

A

MOA: synergism via POMC activation; appetite suppression and reward center effects
Effect on weight: 6.5 kg at 1 yr
SE: nausea, vomiting, insomnia, dizziness, increased HR/BP

46
Q

Liraglutide

A

MOA: GLP-1 central appetite suppression, decreased gastric motility
Effect on weight: 5.9 kg at 1 yr
SE: nausea, vomiting, diarrhea, constipation, flatulence

47
Q

Phentermine

A

MOA: stimulates release of NE in CNS. Differs from amphetamine due to no DA release from synapse
Effect on weight: 3.6 kg at 6 months
FDA approved for 12 weeks or less (short term use)
CI: hyperthyroidism, glaucoma, advanced arteriosclerosis, moderate HTN (no CI if controlled), pulmonary HTN
Monitor blood pressure, weight
Benefit: cost: $34.99/30 30 mg capsules
dosed 18.75-37.5 mg/day