Metab/Obesity2 Flashcards
Is the process of biochemical reactions occuring in the body’s cells that are necessary to produce energy, repair cells and maintain life.
-through the release of hormones, such as insulin, the endocrine system controls the cellular activity that regulates growth and body metabolism.
- Concepts of Metabolism
a disorder of hyperglycemia resulting from defects in insulin secretion, insulin action, or both, leading to abnormalities in carbohydrate, protein and fat metabolism.
Type 1
Type 2
- Concepts of Metabolism (DM)
Destruction of beta cells, usually leading to absolute deficiency of insulin.
- Concepts of Metabolism
Type 1 Diabetes
A range from predominantly insulin resistance with relative insulin deficiency to predominantly secretory defect with insulin resistance
- Concepts of Metabolism
Type 2 Diabetes
Storage of excess calorie fats, resulting from excess energy intake, decreased energy expenditure, or a combo of both. Several hormones are involved in regulating obesity, including thyroid hormone, insulin and leptin. Genetic play a role as well
1 Concepts of Metabolism
Obesity
**Genetics; Type 1 DM
**Type 2 DM; Hx of diabetic parents or siblings
(child 15% chance of developing, 30% developing glucose intolerance)[inability to metabolize carbs normally]
**Obesity; which is 20% over the desired body weight or BMI at least 27 kg/m2.
-Peripheral insulin resistance~decrease the # of available insulin receptor sites in cells of skeletal muscles and adipose tissues.
-obesity also impairs the ability of the beta cells to release insulin in response to increasing glucose levels.
**Physical inactivty
**Race/Ethnicity
**Women-hx of gestational diabetes, polycystic ovary syndrome; or delivering more than 9 lb. baby
**HTN; more than 130/85, decrease HDL, cholesterol levels more than 35 mg/dl and/or triglycerides more than 250 mg/dl
**Metabolic Syndrome; HTN, abd. obesity, dyslipidemia, increase in C-reactive protein, and a fasting blood glucose greater than 100 mg/dl, increase risk of DM2, coronary HD, and Stroke
2.Risk Factors r/t DM & Obesity
prescription for weight loss and increased activity levels
Treatment/preventative measures for DM & Obesity
Type 2: Condition of fasting hyperglycemia that occurs despite the availability of endogenous insulin (produced by ones own body) despite amount produced; available its functioning is impaired by insulin resistance.
-Insulin resistance exceeds the ability of the pancreas to compensate, overtime the pancreas fails to produce enough insulin to meet body needs.
-there is enough to break down fats with resultant ketosis; (an accumulation of ketone bodies produced during oxidation of fatty acids)
(Thus making Type 2; nonketotic form of diabetes)
- Pathophysiology of obesity and DM
- Hx in family
- obesity; BMI more than 27 kg/m2 or greater~peripheral insulin resistance
- physical inactivity
- race/ethnicity
- women, hx of gestational diabetes, big babies more than 9 lbs.
- HTN; more than 130/85 mmHg, decrease HDL, increase cholesterol, and triglycerides more than 250 mg/dL
- Metabolic Syndrome; a disorder characterized by the presence of 3 or more of the following: increase waist circumference, HTN, increase blood triglycerides, and fasting blood sugar, low HDL, cholesterol more than 35 mg/dL
- Risk Factors of DM2
A disorder of hyperglycemia resulting from defects in insulin secretion, insulin action, or both, leading to abnormalities in carbohydrate, protein, and fat metabolism.
- Diabetes Mellitus
Slow onset, often unaware of the disease until healthcare is sought for other issue.
-Hyperglycemia increase gradually
-1/2 of diagnosed (newly) already have complications. (DM2)
-DM2 hyperglycemia not as severe as DM1, but similar symptoms. ie. polyuria and polydipsia, blurred vision, fatigue, paresthesias, and skin infections.
-If available, insulin decrease in times of stress (physical or emotional) may develop diabetic ketoacidosis; but uncommon.
~Hypoglycemic meds begun when lifestyle changes are insufficient.
-usually a combo of insulin and hypoglycemic meds used to achieve best glycemic control.
- Manifestations of DM2 & Obesity
Alterations in blood glucose levels Alterations in cardiovascular system Neuropathies Increase susceptibility to infection Periodontal disease
4. Complications of Diabetes
Hyperglycemia and hypoglycemia, diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS),
4 Acute complications of Diabetes
increase glucose levels
hyperglycemia
a form of metabolic acidosis that develops when there is an absolute deficiency of insulin and an increase in the insulin counterregulatory hormones. It may also be induced by stress in an indiv. with type 1 DM
DKA Diabetic Ketoacidosis
Blood glucose between 4 & 8 am. Not a response to hypoglycemia (type 1 and type 2). [teenagers; growth hormone] decrease peripheral uptake of glucose.
#4. Complications of Diabetes Dawn Phenomenon
Combo of hypoglycemia during the night with a rebound morning rise in blood glucose to hyperglycemic levels. (counterregulatory hormones stimulated)
*gluconeogenesis & glycogenolysis inhibits peripheral glucose use: insulin resistance for 12-48 hrs.
#4. Complications of Diabetes Somogyi Phenomenon
Untreated type1 DM continues, the insulin deficit causes fat stores to break down; the result is continued hyperglycemia and mobilization of fatty acids with a subsequent ketosis
Diabetic Ketoacidosis
When an individual is sick, who has an infection or decreases or omits insulin doses is @ greater risk of
DKA
- HYperosmolarity from hyperglycemia and dehydration
- Metabolic acidosis is from an accumulation of ketoacids
- Extracellular volume depletion from osmotic diuresis
- Electrolyte imbalances (loss of K and Na) from osmotic diuresis.
Diabetic Ketoacidosis
Severe dehydration and acidosis & DKA need immediate medical attention
-blood glucose levels greater than 250 mg/dL, decrease in pH, and ketone in urine.
Manifestations of DKA
Regular insulin is used in the treatment of DKA
-mild ketosis; sub q insulin
-severe ketosis; iv insulin
Regular insulin only insulin giving IV!
Treatment of DKA
Occurs in individuals who have type 2 DM and is characterized by a plasma osmolarity of 340 mOsm/L or greater (normal range 280-300 mOsm/L. Increase blood glucose levels and altered LOC
Onset is slow; 24 hrs to 2 weeks
Life-threatening medical emergency;
**precipitating factors; infection, therapeutic agents, therapeutic procedures, acute illness and chronic illness
**MOST common; infection
Hyperosmolar Hyperglycemic State HHS
Treatment is correcting fluid and electrolyte imbalances, decrease blood glucose levels and give insulin.
Treatment of HHS
decrease blood glucose levels; common in ind. with type 1 DM, occasionally DM2
Hypoglycemia
Insulin Shock; insulin reaction “the lows” in type 1 DM
;results primarily from a mismatch between insulin intake (error of insulin dose), physical activity, and carb availability (omitting a meal)
-intake of alcohol and drugs, such as
-chloramphenicol (Chloromycetin)
-sodium warfarin (Coumadin)
-monoamine oxidase inhibitors
-probenecid (Benemid)
-Salicylates
-Sulfonamides; all can cause hypoglycemia
Hypoglycemia causes
Compensatory ANS response:
-impaired cerebral function; decrease glucose availability to brain
-onset SUDDEN, and blood glucose decrease of 45-60 mg/dL
**Severe hypoglycemia may cause death
Hypoglycemia Awareness; counterregulatory system stops working
15/15 Rule! 15 g. of rapid acting sugar; Apple juice. 1 tsp honey, Wait 15 mins, monitor blood glucose again, then if still low eat another 15 g. of carbs.
Manifestations Hypoglycemia
Alterations in cardiovascular system
- the peripheral & ANS
- mood as well as increase susceptibility to infection
- periodontal disease
- complication involving the feet
Chronic Complications of DM
Changes in lg blood vessels resulting in atherosclerosis Abnormalities in platelets RBC's clotting factors Changes in arterial walls
Chronic Complications
Cardiovascular System changes with DM
major risk factor for developing of an MI.
***MOST common cause of death in an indiv with DM
Chronic Complications
Coronary Artery Disease with DM
more than 140/80 mmHg common comorbidity of DM. Affects 20-60% with diabetes
Complications;
-retinopathy
-nephropathy
-HTN; reduced by weight loss, exercise, and decrease in Na intake and alcohol comsumption.
-plus meds to lower
Chronic Complications
HTN with Diabetes
with diabetes 2-6x more likely to have a stroke.
HTN; risk factor
~atherosclerosis of cerebral vessels develop @ an earlier age and is more extensive with ind. with diabetes.
Manifestations of impaired cerebral circulation are similar-hypoglycemia or HHS, blurred vision, slurred speech, weakness, and dizziness.
Chronic Complications
Stroke with Diabetes
lower extremities accompany both types of diabetes, but greater in ind. with type 2 DM.
Chronic Complications
Peripheral Vascular Disease
refers to the changes in the retina that occur in the ind. with diabetes.
- retinal capillary structure undergoes alterations in blood flow, then retinal ischemia and breakdown in the blood; retinal barrier.
- *Leading cause of blindness in individuals between 20 & 74 years of age.
- Stage I: nonproliferative retinopathy; dilated veins, microaneuryms, edema of the macula; exudates
- Stage II; Retinal ischemia infarcts of nerve fibers “cotton wool”
- Stage III; proliferative retinopathy; traction on the vitreous humor, may cause hemorrhage or retinal detachment.
Chronic complications DM
Diabetic Retinopathy
disease of the kidneys characterized by the presence of albumin in the urine, HTN, edema, and progressive renal insufficiency.
- occurs in 20-40%
- **Single leading cause of end-stage renal disease.
1st indication of nephropathy is microalbuminuria; (a low but abnormal level of albumin in the urine)
*****Aggressive antihypertensive management!!
B/c HTN accelerates the progress of diabetic nephropathy.
Glomerulosclerosis thickens the basement membrane and simultaneously makes it functionally leaky, allowing large molecules (ie. protein) to be lost in the urine.
Chronic complications
Diabetic Nephropathy
fibrosis of the glomerular tissue
Glomerulosclerosis
Peripheral and Visceral neuropathies are disorders of the peripheral nerves and the ANS.
-Ind with diabetes, these disorders are manifestations that depend on where the lesions are located.
Chronic Complications
Diabetic Neuropathies
- a thickening of the walls of the blood vessels that supply nerves, causing a decrease in nutrients.
- demyelinization of the Schwann cells that surround and insulate nerves, slowing nerve conduction.
- Formation and accumulation of sorbitol with in the Schwann cells, impairing nerve conduction.
Etiology on Diabetic Neuropathy
aka Somatic Neuropathies;
-Polyneuropathies and Mononeuropathies
Peripheral Neuropathies
Most common type of neuropathy assoc. with diabetes. (bilateral sensory disorders)
- 1st in the toes and feet, than progress upwards. Possible fingers and hands. Depends on which nerve fibers are involved.
- Distal paresthesias
Polyneuropathies
Isolated peripheral neuropathies that affect a single nerve. ie. Palsy of the 3rd cranial nerve (oculomotor)
Mononeuropathies
Autonomic neuropathies cause various manifestations
- Sweating dysfunction
- Abnormal pupillary function
- Cardiovascular dysfunction
- Gastrointestinal dysfunction
- Genitourinary dysfunction
- Alterations in Mood
- Increase Susceptibility to infection
- Periodontal disease
- Complications involving the feet.
Visceral Neuropathies
Dx test; screening purposes, ongoing lab tests
-Hemoglobin A1C more than 6.5%
-Symptoms of diabetes plus casual plasma glucose more than 200 mg/dL
-Fasting plasma glucose more than 126 mg/dL
-2 hr PG more 200 mg/dL
Pre-diabetes; blood sugar between 100 to 126 mg/dL
Treatment
Dx testing for DM
Blood Sugar between 100 to 126 mg/dL
Pre-diabetes
-Fasting blood glucose (FBG); often ordered if client is experiencing symptoms of hypoglycemia or hyperglycemia. 70-110 mg/dL normal.
Diabetes Management Monitoring
Avg. blood glucose level over 2-3 months.
_Glucose erratic/out of control, it attaches to the hemoglobin molecule and remains attached for the life of the hemoglobin. Avg. 120 days 7-9% elevated
Hemoglobin A1C
Dx test DM
not as accurate in monitoring changes in blood glucose levels.
-presence of glucose in urine indicates hyperglycemia.
180 mg/dL; exceeds glucose not reabsorbed; spilled out into the urine.
Urine glucose & Ketone Levels
Dx urine test DM
the presence of ketones in the urine. Occurs with the breakdown of fats; indicator of DKA.
Ketonuria
Dx urine test DM
Urine test for the presence of protein as albumin (albumin-uria); 24 hr urine test for Creatinine clearance is used to detect early onset of nephropathy
Creatinine
Dx urine test DM
indicate atherosclerosis and an increased risk of cardiovascular impairment.
Serum cholesterol and triglyceride levels
Dx test DM
levels measured in clients who have DKA or hyperglycemic hyperosmolaric state (HHS) to determine imbalances.
Serum electrolytes
Dx test for DM
Monitor Blood glucose
Urine testing for ketones and glucose
Dx testing for DM
increased levels usually test falsely low in blood glucose, and clients with decreased usually test falsely higher.
-Anemia and sickle cell anemia affect hematocrit
Hematocrit levels DM
Insulin; DM 1 must have insulin
DM 2 usually able to control glucose levels with an oral hypoglycemic medication, may require insulin.
-Controls hyperglycemia.
-Regular insulin is unmodified crystalline classified as a short-acting insulin. Only insulin given in an IV.
-Regular insulin used to treat DKA!
-NPH prolong their action, classified as intermediate; or long acting insulin.
-Insulin glargine (Lantus) 24 hr, long acting & DNA human insulin analog SubQ 1 or 2 days both for Type 1 and Type 2
[Levemir (detemir) and Glargine (Lantus)] is clear.
Pharmacology DM
Insulin
Rapid acting; -lispro (Humalog) -aspart (Novolog) -glulisine (Apidra) [all clear] Frog on a Log; rapid tongue to get fly Novolog, Humalog
Pharmacology DM
Rapid acting Insulin
Short acting:
Regular (Novolin R)
Pharmacology DM
Short acting Insulin
Intermediate acting:
-NPH (Novolin R)
-Humulin N
cloudy
Pharmacology DM
Intermediate acting Insulin
Long acting:
glargine (Lantus)
detemir (Levemir)
Pharmacology DM
Long acting Insulin
Combos: Humalog 50/50 Humalog 75/25 Novolog 70/30 Humulin 70/30 Novolin 70/30
Pharmacology DM
Combo Insulin
treat ind. with type 2 lower blood sugar by stimulating or increasing insulin secretion, preventing breakdown of glycogen to glucose by the liver and increase peripheral uptake of glucose by making cells less resistant to insulin.
- Byetta (exenatide)
- Victoza (liraglutide) GLP-1 agonists SubQ
- Januvia (sitagliptin)
- Tradjenta (linagliptin) DPP1V inhibitors
Pharmacology DM
Hypoglycemic Agents
Diabetes ind. 4x more likely to die from CVD
-recommended dose of aspirin 81-325 mg reduce atherosclerosis in clients with vascular disease or increase cardiovascular risk factors.
Pharmacology DM
Aspirin therapy
Careful balance between intake of nutrients, the expenditure of energy and the dose and timing of insulin or oral antidiabetic agents.
Nutrition DM
- Maintain a near normal blood glucose levels as possible balancing food intake with insulin or oral glucose.
- Achieve optimal serum lipid levels.
- Provide adequate calories to maintain or attain reasonable weights, and to recover from catabolic illness.
- Prevent & treat the acute complications of insulin-treated DM, short-term illness and exercise- related problems, or the long-term complications of diabetes.
Nutritional implications for managing DM
Sensible diet choices
- Follow exercise plan
- relate strategies that deal with hunger and making unhealthy food choices
- support group
- demonstrate regular weigh in appointments
Planning Nutrition DM
Exercise, Diet and Behavior modification
- identify food excess intake
- realistic weight loss goals
- 1 to 2 lbs/wk
- knowledge of well balanced diet
- Discuss behavior modification strategies
- Monitor weight loss, bp and labs, including blood glucose and lipid levels
- Encourage Exercise
- Promote Weight loss
- Promote Self-esteem
Implementation: Nutrition Obesity
Focus on Diet, exercise and Behavior Modifications
-Carb Intake 45-60% daily diet
4kcal/g 130g/day
Plant foods, grains, fruits, vegs, milk and dairy products
*simple sugars and complex sugars
- Protein 15-20% 4kcal/g low fat, low saturated fat, low cholesterol; prevent or delay renal complications
- Sat fats; animal meats (meat, butter, fats, lard, bacon) cocoa butter, coconut oil, palm oil, and hydrogenated oils.
- Polyunsaturated fat; oils of corn, safflower, sunflower, soybean, sesame seed & cottonseed
-Monosatured fats; peanut oil, olive oil and canola oil.
limit fat and cholesterol
-Fiber 20%/ day 35g/day
-Limit Na; 1, 000 mg ideal. Do not exceed 3,000mg/day;
2,300 mg recommended
Improve overall health through optimal nutrition, using MyPlate and Dietary Guidelines for Americans
Health Promotion activities primarily focus on Preventing the complications of diabetes.
- prevent or decrease excess weigh
- follow a sensible and well balanced diet
- maintain a regular physical exercise program
- combo with meds and self monitoring
Nursing Process in management of patients with DM & Obesity (5)
Family hx, HTN, cardiovas prob. hx of dizziness, numbness, esp. in hands and feet, pain when walking
-freq need to void, change in weight, appetite, infections and healing, problem with GI or urination, sexual function.
Assessment Health hx
(5) Nursing Process for DM & Obesity
H&W ratio, VS, visual acuity, cranial nerves, sensory abilities in extremities (hot/cold), peripheral pulses, and skin & mucous membranes (hairloss, appearance) lesions, rash, itching, and vaginal discharge.
Physical assessment
Nursing Process for DM & Obesity 5
- Knowledge deficit
- Risk for Impaired Skin Infection
- Risk for Infection
- Risk for Injury
- Risk for Deficient Fluid Vol
- Sexual Dysfunction
- Ineffective Coping
Diagnosis DM & Obesity
Nursing Process 5
Provide self care and reduce risk of complications.
- describe how to administer meds and respond to side effects.
- demonstrate meal planning
- proper foot care and inspection
- proper procedure for monitoring blood sugar.
- describe strategies for reducing risk of infection.
Planning DM & Obesity
Nursing Process 5
Teaches about the disease and management, planning dietary intake, providing emotional support, and creating strategies for daily management.
@ home teaching;
-information about normal metabolism, diabetes and how diabetes can change metabolism.
@ home diabetes care:
-how diet keeps blood glucose in normal range. # of kilocalories required and why?, amount of carbs, meats and fats allowed, and why?, how to calculate the diet while integrating personal food preferences.
-how to exercise to lower blood glucose, importance of a reg exercise program, types of exercise, integrating personal exercise preferences, and how to handle activity.
-Self monitoring of Blood Glucose; how to use equipment and what to do about high &/or low blood glucose.
Implementation; for DM & Obesity
Nursing Process 5
Insulin: intravenous agents:
Type, dosage, mixing instructions, time of onset and peak actions, Get and care for equipment. How and where to give injections
-Manifestations; (acute complications) of hypoglycemia and hyperglycemia
What to do if they occur.
-hygiene, ie skin care, foot care, dental care
-what to do on a sick day
-helpful resources.
Medications;
Nursing Process DM & Obesity
Changes in diet may be difficult.
- changing bad habits.
- maynot be eating balanced meals ever
- purchasing, storing and preparing foods may be a problem
- dentures might not fit well.
- Changes in taste buds, increase salt and sugar intake.
-Need to exercise, may not be apart of life implement an exercise plan
-Dx of chronic illness threatens indep. and self worth (often leads to withdrawal)
-$ to purchase medications and supplies often taken out of fixed income.
-Visual deficits may make insulin diff. to admin.
Can interfere with monitoring, food prep, exercises and foot care.
Older people considerations DM & Obesity
@ increased risk for decreased tissue perfusion, infection, and decreased or absent sensations from neuropathies.
- teach foot care/hygiene
- smoking cessation
- discuss importance of blood glucose r/t diet, meds and exercise.
- **Hyperglycemia promotes growth of microbes.
- conduct foot care teaching sessions.
Maintaining skin Integrity DM & Obesity
_Ind. with diabetes have increase risk for infection.
- Handwashing!!!
- monitor manifestations of infection
- Increase temp, swelling, discharge, etc.
- Discuss import. of skin care
- Dental health
-Teach women symptoms and prevention of yeast infections.
Promoting Healthy Behaviors DM & Obesity
-Neuropathies; alter sensations, gait, and muscle control.
-cataracts or retinopathy (visual deficits)
-hyperglycemia can cause blurred vision.
Increase risk of accidents, burns, falls, and trauma
- Safety in home (teaching) and community
- Monitor for & teach about recognizing and seek care for manifestations of DKA in type 1 DM
- Monitor for and teach to recognize and seek care for manifestations of HHS with type 2 DM
- Monitor for & teach to recognize and treat the manifestation of hypoglycemia; decrease blood glucose, anxiety, HA, uncoordinated movements, sweating, rapid pulse, drowsiness and visual changes.
- Reduce environmental hazards
- Recommend client wear a bracelet or alert necklace, incase of accident.
Maintain Safety for client with DM
Sexual dysfunction (50% men) usually due to perpheral neuropathy.
-Libido usually not affected.
Women have less problems.
-include sexual hx
Provide info on actual and potential physical effects of diabetes on sexual function.
-provide counseling
Maintaining Sexual Health DM
-Assess psychosocial resources.
emotional, support, financial, life style, communication skills
-explore effects from diabetes
-teach constructive problem solving techniq.
-Provide info on support groups.
Promote Effective coping DM
Demonstrate an age appropriate understanding if diabetes self-management through meds, diet, exercise and blood glucose self monitoring activities.
- client skin integrity remains intact
- remains free of infection
- remains free of injury
Diabetes Mellitus (DM) is a disorder of metabolism that results in hyperglycemia due to a defect in insulin secretion, insulin action, or both.
Evaluation/Goals Diabetes
Serious physiological and psychological consequences and is assoc with increase morbidity and mortality
Obesity
an excess of adipose tissue is one of the most prevalent preventable health problems in the US
Obesity
Upper body obesity; central obesity waist-to-hip-ratio; greater than 1 in men or 0.8 in women
- tend to have more intra-abdominal fat increased levels of circulating free fatty acids.
- *Assoc risk HTN, abdominal blood lipid levels, heart disease, stroke and elevated insulin levels.
Clinical Manifestations of Obesity
Lower body obesity; (peripheral obesity)
waist-to-hip ratio; less than 0.8 and is most common in women. Risk for hyperinsulinemia, abnormal lipids and heart disease.
Clinical Manifestations Obesity
exercise, diet, and behavior modification. Pharmacology recommended if all else fails
Treatment for Obesity
bariatric surgery;
usually limited to clients obese more than 40 kg/m2 waist
unable to lose through diet and exercise or serious issues with metabolic syndrome, HTN, heart disease
Surgical Treatment for Obesity
-Cardiovascular disease
-HTN
-Coronary heart disease (CHD)
-Heart Failure
60% of obesity have Metabolic Syndrome
-Increase in waist circum., HTN, increase blood triglycerides, and fasting blood glucose. decreased HDL Cholesterol (want higher than 40)
-Identified risk factor for atherosclerosis and CHD
-heart failure; Left ventricular muscle mass increase, ventricle dilates b/c blood volume and increased CO.
-Obesity assoc obstructive sleep apnea
***Increase risk of Insulin resistance and type 2 DM
Complications of Obesity
- Affects reproductive function in Men and Women
- Increase risk for developing Gallstones
- several types of cancer
- increase in stress on joints, osteoarthritis
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Endocrine and reproductive
- Other; depression, eating-binge disorder, post-op complications
Complications of Obesity cont.
- BMI
- Anthropometry; h&w, bone size, skin folds
- Underwater weighing (hydrodensitometry)
- Bioelectrical impedance
- Waist circumference
- Thyroid profile
- Serum glucose
- Serum cholesterol
- Lipid profile
- Electrocardiography
Dx tests for Obesity
- OTC, prescription
- Amphetamines (increase potential for abuse)
- Non-amphetamines suppressants (ie. phentermine)
- Short-term promote weight loss; acts directly on appetite control center in CNS.
- amphetamines; increase alertness, nervousness, and insomnia, reduce fatigue, can interfere with sleep.
- *Use caution with heart patients
Pharm Therapy for Obesity
-Sibutramine (Meridia); appetite suppressant acts on CNS.
Increase metabolic rate, lower cholesterol and triglyceride levels, but increase pulse rate and bp (limit for HTN, CHD, or heart failure pt)
Pharm therapy for obesity
