ICL 5.3: Obesity: epidemiology and Treatment Options vs. Surgery Flashcards
what is the diagnostic term for obesity?
adiposity based chronic disease (ABCD)
why is obesity a disease state?
- impairment of normal function
ex. physical impairments, altered physiologic function like inflammation, dyslipidemia etc. - characteristic signs or symptoms
ex. increased total body and visceral fat mass, altered metabolism, sleep apnea, joint pain, impaired mobility, low self esteem - bodily harm or morbidity
ex. CVD, type II DM, metabolic syndrome, cancer, death
what is the definition of obesity?
abnormalities in adipose tissue in mass, distribution and function
it’s a life long disease with complications and the phathophysiology is consistent with the 3 phases of chronic disease prevention
how common is obesity?
Increasing sharply over past 30 years → creating global public health crisis
500 million adults worldwide have obesity
Prevalence increasing among children and adolescents
Roughly 2 of 3 US adults are overweight/obese [NHANES]
1 of 3 adults has obesity
Obesity is estimated to add $3,559 annually to per-patient medical expenditures as compared to pts who do not have obesity
which states have the highest obesity?
west virginia at 38%
what causes obesity?
it’s an abnormal energy balance
energy intake and energy expenditure are unbalanced
what’s the effect of gherkin?
it increases food intake; makes you feel hungry
made by the stomach
what is the effect of CCK?
made by the I cells in the proximal intestine
decreases food intake
what does GIP and GLP1 do?
GIP from K cells in proximal intestines and GLP1 from L cells in distal intestine
increase insulin secretion and decrease GI emptying
what is the function of PYY?
decreases food intake
secreted by distal small intestine
what is the hunger-satiety pathway?
one group of neurons coproduce: NPY (neuropeptide Y) & AGRP (agouti-related peptide) → which leads to stimulation of feeding
POMC (proopiomelanocortin): results in secretion of α-melanocyte-stimulating hormone (α-MSH) → (+) neuronal melanocortin receptor 4 neurons in paraventricular nucleus of hypothalamus → inhibits food intake
which hormones play a roll in the hunger-satiety pathway and what do they do?
- Leptin (produced by adipose tissue) → inhibits food intake
(+) POMC
(-) AGRP neurons - Ghrelin (produced by stomach) → stimulates food intake
(-) POMC - GLP-1 →
acts peripherally → slowing gastric emptying and also centrally → directly regulating appetite
which hormones increase appetite?
decrease in GLP1
increase in nPY, AGRP, ghrelin
which hormones decrease appetite?
MC4R
which hormones increase appetite?
increased ghrelin
however there’s decreased leptin, PYY, CCK and amylin and they’re all fighting against weight loss biologically
which factors effect body weight?
- biological factors (birth weight, gender, age, in utero environment)
- genes
- environment
- behavior (dietary preferences, physical activity, psychological factors, diurnal life patterns)
what are the stages of obesity?
normal: BMI under 25 – work on primary prevention
overweight stage 0: BMI 25-29.9, no obesity related complications – work on secondary prevention
obesity stage 0: BMI over 30, no obesity related complications – work on secondary prevention
obesity stage 1: BMI over 25, presence of 1 or more mild to moderate obesity related complications – tertiary prevention
obesity stage 2: VMI over 25, presence of one or more severe obesity related complications – tertiary prevention
how do you manage obesity?
- life style intervention
- medications
- bariatric surgery
what is the comprehensive lifestyle management for obesity treatment?
MEAL PLAN
1. reduced calories; 500-750 kcal daily deficit
- many healthy meal plan options
- meal replacements
- very low calories diet
PHYSICAL ACTIVITY
1. aerobic activity; goal is 150+ minutes a week, 3-5 days a week
- resistance exercise for major muscle groups 2-3 times a week
- reduce sedentary behavior
BEHAVIOR
1. intervention package of behavioral methods
- self monitoring: goal setting, education, problem solving, stimulus control, stress reduction, social support structures
which medications are good for weight loss?
- orlistat
- phentermine/topiramate
- naltrexone/buprion
- liraglutide
what is the MOA of orlistat?
peripheral pancreatic lipase inhibitor which blocks ingested fat absorption
what is the MOA of phentermine/topiramate?
symphathomimetic
anticonvulsant: GABA receptor modulator carbonic anhydrase inhibitor, glutamate antagonist
what is the MOA of naltrexone/buprion?
opioid receptor antagonist – mu receptor actvivation inhibits POMC pathway so when you antagonist mu receptors you stimulate POMC pathway
dopamine/noradrenaline reuptake inhibitor
what is liraglutide?
GLP1 receptor agonist
what are the side effects of orlistate?
all the symtpoms of steatorrhea
what are the side effects of lorcaserin?
headache, dizziness, fatigue
what are the side effects of phentermine/topiramate?
- paresthesias
- dysgeusia
- dizziness
- dry mouth
what are the side effects of naltrexone/bupriopion?
- N/V
- headache, dizziness
- insomnia
what are the side effects of liraglutide?
- N/V
2 diarrhea
- constipation
- dyspepsia
- abdominal pain
what are the contraindiciations for orlistat?
chronic malabsorption or gall bladder disease
what are the contraindiciations for phentermine/topiramate?
- glaucoma
- hyperthyroidism
- MAOIs
- pregnancy
what are the contraindiciations for naltrexone/bupropion?
- seizure disorder
- uncontrolled HTN
- chronic opioid use
- pregnancy
what are the contraindiciations for liraglutide?
- patients with personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia
- pregnancy
also be away of people with pancreatitis
what are the complications of obesity>
- dyslipidemia
- prediabetic states
- HTN
- NAFLD
- PCOS
- CVD
depression, cancer, gallbladder disease, sleep apnea, osteoarthrisitis, GERD, stress incontinence, disability
A 33-year-old morbidly obese woman comes to the physician to discuss weight loss. She is 167 cm (5 ft 6 in) tall and weighs 142 kg (315 lb); BMI is 50.8 kg/m2. Her blood pressure is 150/90 mmHg, respiratory rate is 24/minute, and pulse is 90 beats/minute. Which of the following is the most appropriate initial step in the management of this patient?
a) Dietary and caloric intake modification
b) Diet and exercise counseling
c) Laparoscopic adjustable gastric band placement (Lap Band)
d) Liposuction
e) Gastric bypass surgery
f) Pharmacologic intervention
b) Diet and exercise counseling
> 2/3 of adults in the US are either trying to lose/maintain weight.
However, only 20% are eating fewer calories AND engaging in at least 150 minutes of physical activity during leisure time each week.
For initial weight loss, treatment should be aimed at decreasing food intake and, when possible, increasing energy expenditure.
Educate & counsel the patient on a proper diet (e.g. caloric intake, low fat foods, etc.) and introducing exercise into their daily routine. If this is unsuccessful, other approaches may need to be considered.
what are the indications for bariatric surgery?
- BMI ≥40 kg/m2 without coexisting medical problems and no excessive surgical risk
- BMI ≥35 kg/m2 and 1 or more severe obesity-related co-morbidities
- BMI 30–34.9 kg/m2 with diabetes or metabolic syndrome may be offered surgery, however evidence limited by the number of subjects studied lack of long-term data demonstrating net benefit
what are the types of bariatric surgery?
- Biliopancreatic Diversion (with or without duodenal switch) [BPD]
- Roux-en-Y Gastric Bypass [RYGB]
- Sleeve gastrectomy [SG]
- Laparoscopic and Adjustable Gastric Banding [LAGB
what is the biliopancreatic diversion?
make the stomach smaller and also attach the end of the jejunum to the duodenum
what is the ROUX-en-Y gastric bypass?
Proximal jejunum divided at about 50 cm from the duodeno-jejunal flexure
15 ml (3 tablespoons) gastric pouch left
Procedure takes 90-150 minutes
Patient stays inpatient overnight
what is a sleeve gastrectomy?
Excision of about 80% stomach
50-80 cc new stomach pouch
Antrum preserved to maintain gastric emptying
Non-adjustable
Non-reversible
“Sleeve and leave”
how effective is weight loss after bariatric surgery?
Weight loss generally maintained for many years, but patients typically remain with a BMI > 30 kg/m2
Nadir between 1 and 2 years post surgery
Gastric banding least effective
Sleeve gastrectomy only lightly less effective than RYGB
what is diabetes remission?
partial remission is A1V 6.5% or lower
complete remission is A1c under 6
also must be off all diabetes medications and maintenance of these glycemic levels for at least 1 year
