Lecture 4: Obesity Part 2 Flashcards
What are some of the common behavioral interventions for obesity?
Setting realistic goals using body weight %.
Self-monitoring
Stimulus control
Slowing eating style
Nutritional education
Meal planning
Stress reduction and problem solving
What is the standard minimum for physical activity?
30 minutes a day, 5 days a week.
What is the ultimate goal of a diet as obesity intervention?
Reducing caloric intake.
What should we remember to keep in mind while dieting?
Ensuring adequate nutrition still.
Consider food volume relative to its density.
What kind of foods in general are calorie dense?
Processed foods.
What is the usual kcal/day goal for a diet?
1000-1500.
What is considered a low-cal diet?
200-800 kcal/day.
What is the most important consideration when doing obesity interventions?
Patient compliance!
No point in doing all this if the patient is not willing.
Is there any advantage to a specific diet?
No.
Low-carb may have a fast initial weight loss.
What are the general guidelines for prescribing an anti-obesity medication?
Adult use only EXCEPT FOR orlistats/xenical (12+).
BMI >= 30, >=27 if 1+ comorbidity present.
Most are 12 weeks or less. Efficacy is measured at 12 weeks.
Cost
What is the MOA of phentermine/Adipex?
Sympathomimetic that stimulates NE release.
Schedule 4 medication, short-term use only. (12 wk)
Historically, it was the MOST prescribed rx for weight loss in the US.
Suppresses appetite/causing early satiety.
What SE come from phentermine/adipex?
HTN
Tachycardia
Insomnia
Agitation
Palpitations
Constipation
Dry mouth
AKA NE release SE.
What are the main CIs to phentermine/adipex?
Allergy
CVD
Hypothyroidism
Agitated State
Substance use hx
What are the DDI for phentermine/adipex?
Psych meds
AntiHTNs
Antihistamines
Insomnia meds
What is the efficacy in terms of weight loss for phentermine/adipex?
7-8kg
What is the MOA of orlistat/xenical?
Inhibition of intestinal lipase, blocking FAT absorption.
Causes dose-dependent increases in fecal fat excretion.
Blocks 25-30% of the calories absorbed from fat.
Also helps BP and lipid profile as a result.
What are the SE of orlistat/xenical?
Borborygmi
Cramps
Flatus
Oily spotting
Fecal incontinence.
Decreased absorption of the fat-soluble vitamins.
What are the rare SE of orlistat/xenical?
Liver injury
Calcium oxalate stones
AKI
What are the CI of orlistat/xenical?
Allergy
Pregnancy
Cholelithiasis
Hx of kidney stones
Chronic malabsorption syndrome
What are the DDI of orlistat/xenical?
Multivitamins
Fat-soluble vitamins
Warfarin
Levothyroxine
What is the efficacy in terms of weight loss for Orlistat/xenical?
5-10kg
What is the removed drug for obesity from the US market?
Lorcaserin/Belviq
What is the efficacy in terms of weight loss for Orlistat/xenical?
5-10kg
What is the MOA of liraglutide/saxenda and semaglutide/wegovy?
GLP-1 agonists.
Originally made for DM pts.
Increased insulin release.
Decreased glucagon release.
Slows gastric emptying.
How are liraglutide and semaglutide administered?
Injection.
Lira is daily.
Sema is weekly.
What are the primary SE of liraglutide and semaglutide?
N/V
Diarrhea
Hypoglycemia
Anorexia
What are the rare SE of liraglutide and semaglutide?
Pancreatitis
Gallbladder disease
Kidney injury
What are the CIs of liraglutide and semaglutide?
Allergy
Pregnancy
Personal or FMHx of medullary thyroid cancer or MEN 2A or 2B.
What are the DDIs of liraglutide and semaglutide?
Other hypoglycemic agents.
Serotonergic drugs
Thiazides
What is the efficacy in terms of weight loss for liraglutide and semaglutide?
7-8kg for lira.
10-15kg for sema.
What is the MOA of tirzapetide/mounjaro?
GLP-1 and GIP receptor agonist
Originally made for DM pts.
Increased insulin release
Decreased glucagon release
Slowed gastric emptying.
Better effect than GLP-1 agonist alone.
How is tirzapetide/mounjaro administered?
SC injection into the abdomen, thigh, or upper arm.
What are the main SE of tirzapetide/mounjaro?
N/V
Diarrhea
Hypoglycemia
Anorexia
Essentially its the same as tiraglutide and semaglutide.
What are the CIs and DDis of tirzapetide/mounjaro?
Identical to tiraglutide and semaglutide.
What are the main differences between the two glutides and tirzapetide?
Tirzapetide is also a GIP agonist.
Tirzapetide has a wider efficacy range of 7-20kg.
What is the MOA of cellulose and hydrogel (plenity)?
Expands in the GI tract to create a sensation of satiety.
It is classified as a medical device.
No duration restriction.
What are the main SE of plenity?
Diarrhea
Adominal distension
Pain
Caution in pts with GI motility issues.
What are the CIs of plenity?
Allergy
Pregnancy
What is the MOA of naltrexone SR/Bupriopion SR (Contrave)?
Opioid antagonist/NE and dopamine reuptake inhibitor.
Decreased appetite.
What are the main SE of contrave?
Nausea
Constipation
HA
Vomiting
Dry mouth
Stimulant-like effects
NOT RECOMMENDED FIRST-LINE.
What are the CIs of Contrave?
Allergy
Pregnancy
Uncontrolled HTN
Epilepsy
Anorexia/bulimia
MAOI use in past 2 weeks
Current use of opioid of bupriopion
What are the DDIs of contrave?
ETOH
psych meds
opiates
metoprolol
What is the efficacy in terms of weight loss for contrave?
5-10%
What is the MOA of phentermine/topiramate (Qsymia)?
Stimulates NE release/anticonvulsant
SCHEDULE 4 medication. (12 wk use only)
Suppresses appetite/causes early satiety.
What are the main SE of Qsymia?
Dry mouth
Constipation
Paresthesia
What are the CIs of Qsymia?
Allergy
Hyperthyroidism
Glaucoma
Substance USE HX
MAOI use in past 2 weeks
Pregnancy
What are the DDIs of Qsymia?
ETOH
Psych meds
AntiHTNs
Insomnia meds
Loop diuretics
metformin
What is the efficacy in terms of weight loss for Qsymia?
8-10kg
What is the MOA of HCG?
Increased metabolic rate and appetite suppression.
Given along with a low-cal diet to maintain muscle tone.
Is HCG recommended?
No.
No proof of increased weight loss over a placebo.
Efficacy is therefore unknown.
Who is a candidate for bariatric surgery?
BMI >=40
BMI>=35 + an obesity-related comorbidity.
BMI >= 30 if metabolic syndrome or severe, uncontrollable T2DM.
What are the obesity related comorbidities?
T2DM
HTN
HLD
OSA
NAFLD/NASH
OHS
GERD
Asthma
Pseudotumor cerebri
Severe OA
Severe UI
Impaired quality of life
Cannot get other surgeries
What do you usually need to do prior to bariatric surgery?
Medically guided weight loss program.
Pre-op assessment.
What are the CIs to bariatric surgery?
Not obese
Age <18 or >65
Psychiatric history (bulimia)
Alcoholic
Pts who can’t withstand anesthesia or are non-compliant.
What are the two things bariatric surgery affects in the body?
Restriction: limitation of food intake.
Malabsorption: Decreases nutrient absorption.
What is a Roux-en-Y Bypass (RYGB)?
Most common bariatric surgery, anastomosing a small pouch to the small bowel.
Restrictive and malabsorptive.
Usually causes 70% of excess weight loss.
High complication rate of 40%:
Healing
Nutritional deficiences (anemias)
Gallstones.
Image of RYGB
What is a sleeve gastrectomy? (SG)
Removal of greater curvature of the stomach.
MC procedure in the world in 2016.
Easier and safer to perform than RYGB.
Mostly restrictive.
Excess weight loss of 60%
Complications still present:
Healing (more surgical site leak than RYGB)
Long-term GERD (more than RYGB)
Nutritional (less than RYGB)
Image of SG
What is a laparoscopic adjustable gastric banding (LAGB)?
Compartmentalization of upper portion of stomach via an adjustable, prosthetic band.
Declining popularity.
Modest amt of weight loss.
High rate of revision and weight regain.
Works solely as a restrictive procedure.
Excess weight loss of 50%.
Less complications than SG or RYGB:
Device failures
Long-term esophageal erosion and weight regain.
Image of LAGB
What is liposuction?
Removal of fat tissue via aspiration.
No influence on comorbidity development/progression.
Purely cosmetic.
What is aspiration therapy?
Percutaneous gastronomy tube placed endoscopically.
You can drain some of the food you eat.
Not endorsed by ASBMS.
What is a biliopancreatic diversion with duodenal switch (BPD/DS)?
Done for BMI 50+.
Technically difficult procedure with high rates of complications.
SADI-S is a variant done using SG to lower complications.
What is an intragastric balloon?
SAline filled balloon placed endoscopically for 6 months.
Increased feeling of satiety by reducing gastric volume.
Newer procedure, 30% weight loss.
Image of BPD/DS
Image of Intragastric balloon
