Internal Medicine 16: 45-year-old man who is overweight Flashcards
Medical History for Patients with Obesity
- Ask about symptoms of medical conditions which might predispose patients to secondary obesity.
- Cushing’s syndrome (easy bruising, hyperpigmentation, muscle weakness)
- Hypothyroidism (fatigue, cold intolerance, constipation)
- Hypogonadism (decreased libido) - Ask about symptoms of medical conditions associated with obesity, including symptoms of cardiovascular disease.
- Sleep apnea (snoring, daytime somnolence, and morning headaches)
- Cardiovascular disease (chest pain or pressure or dyspnea)
- Cerebrovascular disease (changes in vision or focal neurologic symptoms)
- Peripheral vascular disease (claudication)
Numerous findings on physical exam can be clues to underlying risk factors for CHD. (coronary heart dz)
Findings of hypercholesterolemia:
Plaques or nodules composed of lipid-laden histiocytes, called xanthelasma (on the eyelids) and xanthomas (on extensor tendons)
Findings of vascular disease: Carotid bruits Diminished peripheral pulses HTN Increased abdominal aortic size (the diameter of a normal abdominal aorta should be less than 2 cm)
Other findings indicating increased risk of CHD:
Increased waist circumference (> 40 inches in men, > 35 inches in women)
Increased waist-to-hip ratio (> 0.85 for women or > 0.90 for men)
Health Risks Associated with Obesity
The metabolic effects of obesity increase the risk of a number of common medical conditions, including: Type 2 diabetes mellitus hypertension dyslipidemias heart disease stroke peripheral vascular disease
Other adverse health outcomes associated with obesity: congestive heart failure atrial fibrillation chronic back pain osteoarthritis venous thromboembolic disease cholelithiasis hepatic steatosis gastroesophageal reflux obstructive sleep apnea
Patients with a BMI ≥ 40 also have higher death rates from a number of cancers, including:
non-Hodgkin’s lymphoma
multiple myeloma
cancers of the esophagus, colon, rectum, liver, gall bladder, pancreas, stomach, kidney, prostate, breast, uterus, cervix, and ovary.
The National Cholesterol Education Program defines the metabolic syndrome as any three of the following five:
Fasting plasma glucose equal and above 100 mg/dL (or on medical therapy for hyperglycemia)
BP ≥ 130/85 mmHg (or on medical therapy for hypertension)
Triglycerides ≥ 150 mg/dL (or on medical therapy for hypertriglyceridemia)
High density lipoprotein (HDL) cholesterol < 40 mg/dL for men, < 50 mg/dL for women (or on medical therapy for low HDL cholesterol)
Abdominal obesity (waist circumference > 40” for men, > 35” for women)
Metabolic Syndrome MECHANISM
Insulin resistance is believed to be the underlying mechanism of the metabolic syndrome. There is some controversy about the existence of a metabolic syndrome, as opposed to a collection of independent risk factors; however this distinction should not discourage appropriate risk factor management and risk reduction.
Causes of Secondary Dyslipidemias
Type 2 diabetes mellitus and insulin resistance are associated with hypertriglyceridemia and low HDL cholesterol.
Cholestatic or obstructive liver disease , such as primary biliary cirrhosis, may lead to elevated total cholesterol levels. This is also associated with xanthomata.
Nephrotic syndrome causes high serum total and LDL cholesterol concentrations as well as triglycerides due to increased hepatic production and diminished lipid catabolism.
Hypothyroidism is a common cause of hypercholesterolemia and hypertriglyceridemia.
Acute hepatitis can cause hypertriglyceridemia.
Alcohol is also a secondary cause of hypertriglyceridemia.
Thiazide diuretics, beta blockers, and oral estrogens and protease inhibitors can cause modest changes in serum lipid concentrations.
The Five A’s of Behavioral Counseling
- Assess the patient’s dietary practices and related risk factors.
- Advise the patient to change dietary practices.
- Agree with the patient on goals.
- Assist the patient in changing dietary practices or addressing motivational barriers. 5. Arrange follow-up, support, and/or referral for the patient.
There are four groups of patients who are most likely to benefit from statin therapy:
- Current ASCVD
- LDL cholesterol > 190 mg/dL
- Diabetes (type 1 or 2) age 40-75 years
- Estimated 10-year ASCVD risk by Pooled Cohort Equations > 7.5%.
Lipid-lowering Medications
- Statins (HMG-CoA reductase inhibitors) are first-line therapy for most patients who require lipid-lowering therapy
- stabilize existing plaques, decreasing the risk of plaque rupture and myocardial infarction
- decrease CHD and all-cause mortality
- decrease LDL by 18% to 55%
- increase HDL by 5% to 15%
- decrease triglycerides by 7% to 30%
Bile acid sequestrants, such as cholestyramine, have a more modest effect on lowering LDL and raising HDL but can cause an increase in triglycerides. Usage has been limited by severe gastrointestinal distress and constipation. According to ACC/AHA guidelines, a non-statin lipid-lowering drug may be considered for patients with untreated LDL cholesterol < 190 after maximum intensity statin therapy has been achieved. Although some of these agents have beneficial effects on HDL cholesterol and/or triglycerides, there is little data to support beginning therapy to treat low HDL cholesterol or mild to moderate hypertriglyceridemia to prevent ASCVD.
Nicotinic acid (niacin, or vitamin B3) has a more modest effect on LDL. However, it is the most effective agent to increase HDL (by 15% to 30%). It can also decrease triglycerides (by 20% to 50%). Studies have shown conflicting results regarding use of nicotinic acid to prevent ASCVD. Usage of niacin has been limited by symptomatic body flushing. This flushing can be reduced by taking aspirin before the niacin dose.
Fibric acid derivatives are first-line therapy for reducing triglycerides but have only a modest effect on reducing LDL. They can increase HDL-cholesterol by 10% to 20%.
Ezetimibe inhibits absorption of cholesterol at the intestinal brush border and increases cholesterol clearance. Although LDL decreases with ezetimibe, there is no clear evidence of benefit in prevention of ASCVD when used as monotherapy or in combination with a statin.
Fish oil supplements have been shown to decrease triglycerides by 25% to 30%. They also increase HDL cholesterol slightly. Small studies suggest some decrease in progression of atherosclerosis in patients taking high doses of fish oil.
Non-pharmacologic interventions to lower LDL
> > Mediterranean-style diet (the DASH dietary pattern achieves this).
Reduce percent of calories from saturated fat, aiming for a goal of 5-6% of calories from saturated fats.
Reduce percent of calories from trans fat.
Reduce sodium intake
Exercise
Oral drug therapy
Phentermine Diethylpropion Pendimetrazine Benzphetamine
Noradrenergic appetite suppressant
tachycardia insomnia headache dizziness anxiety constipation diarrhea vomiting
Indicated for short-term (a few weeks) only
Orlistat Gastrointestinal lipase inhibitor Decreases fat absorption gastrointestinal discomfort fecal incontinence malabsorption of fat-soluble vitamins Available without a prescription
Lorcaserin
Highly selective serotonergic receptor agonist appetite suppressant
headache dizziness nausea cough constipation
Associated with hypoglycemia in diabetic patients
Qsymia(combination Actsviamultiplepathwaysto of phentermine and suppress appetite
dizziness insomnia
cognitive changes
tachycardia constipation
Contraindicated in pregnancy
topiramate)

Contrave
(naltrexone/bupropion)
Naltrexone is an opioid antagonist, and bupropion is a relatively weak inhibitor of the neuronal reuptake of dopamine and norepinephrine.
headache sleep disorder constipation nausea vomiting hypertension tachycardia
Not approved for use in the treatment of major depressive disorder, other psychiatric disorders, or smoking cessation. To be used with caution in patients with cardiovascular or liver disease.
