Obesity Flashcards
Define the following
Obestiy
Metabolic Syndrome
Obesity: a BMI >30
- a compelx, pregressive and chronic conditions which adiposidy developes and increases an individuals risk for other chronic conditions
- need to make this diagnosis to put in pts. chart, allow them to understand the complexity and risk factors which surround such a disease state
Metabolic Syndrome: the presence of 3+ of the following conditions
- Central Adiposity: Men > 40 inches at the waist, Women > 35 inches at the waist
- Elevated triglycerides > 150
- low HDL: Mne < 40, women < 50
- increased blood presure: > 130/80 or being treated for HTN with antihypertensive
- elevated blood sugar: > 100 at fasting
BMI Classifications
underweight
normal
overweight
obesity
Class 1 obese
Class 2 obese
Class 3 obese (morbid)
< 18.5 = underweight
18.5-25 = normal weight
125-30 = overweight
30+ = obese
30-35 = class 1
35-40 = class 2
40+ = class 3
pediatrics is determined by percentile in the weight class with > 95th percentile indicating obesity in children
73.6% of the US is overweight, 41.9% is obese & childhood obesity inc.
Implications of Obestiy & Effects of Stigma
Patho of why obestiy leads to other diseases- briefly
Obesity is associated with the leading causes of death, decreased mental health and redcued quality of life
Pathophysiology
- increase adipose tissue results in a VARIETY of disease processes
- proinflammatory markers-insulin resistances - T2DM
- increased lipids - NAFLD, cirrhosis, CAD and CHF, stroke, CKD
- increase RAAS system, compression of renal system, CHF, stroke and CKD
- mechanial stress from increase weight compresses joints, OSA, GERD and barretts
Obesity Related Disorder (lots)
- HTN, dyslipidemia
- T2Dm
- CAD, stroke
- pain & dysnfuciont
- cancers
- OSA
- gallbladder disease
- ostearthritis
- mental illness
Stigma
- conscious and unconscious stimga impacts patients, their ability to seek out care, communicate and stress/health is impicated as a result
What to do: Stigma
- welcoming environment, larger chairs, etc.
- person-first langugage
- focus toward wellbeing and health lifestlye not weight dropping
Pathophysiology of Obesity
explain the Metabolic/homestatis pathway (hormone players)
explain the hedonic pathway
Lifestyle
- there is sedinatry lifestyle, poor eating habitis and excess caloric intake associated with obesity
However, in addtion there is various pathwats assocaited with obestiy and genetic components as well
40-70% of obesity is explained by genetics
The Metabolic/Homeostatis Pathway
- controlled by the hypothalmus
- the body has a “set point” weiht where the energy balance is maintained
- this set point, responds to decrease calories, weight by increasing appetite stimuli from teh gut, pancreas, adipose and liver
Hormones at Play with the Metabolic Homeostatic Path
Lepitin= satiety hormone secreted by adipose tissue
Ghrelin = hunger hormone from stomach
insulin - uses glucose to store
Incretine Hormones (GLP-1 and GIP): satiey hrmones that are released from the gut
Hedonic Pathway
- the mesolimbic reward center is excited when food is consumed without the need for the “hunger” hormones to cue
- this results in an individual to eat without the hunger hormone cue, to satisfy the dopamine and serotonin pathways that trgger reward
- this can be the drive for binge eating, stress-eating etc.
- influenced by environment, congition and emotions
What are some secondary causes of obesity
Endocrine Related
- hypothyroidims
- cushings
- GH deficient
- psueohypoparathyroid
Psychological
- depression
- eating disorder
Drug-Induced
- TCAs
- OPCS
- antipsycotics
- steroids
- sulfonureas, glitazones (DM medications)
- beta blocker
Physical Exam Findings which can be seen with Obese patients
Acanthosis Nigricans: insulin resistance
Skin Tags: insulin resistance
Hirsutism: insulin resistance
xanthelasma: cholesterol increased
Dorsocervical Fat Pad “Buffalo Hump” : cushings with excess cortisol
Diagnosis of Obesity
Labs
suspect and dx. with labs and BMI > 30
Labs
Hemoglobin a1c
- 5.7-6.4 = prediabetic
- 6.5 = diabetes
Fasting Lipid Panel (look at the Tg:HDL ratio, gives idea of insulin resistance)
CBC (anemia)
CMP (LFTs, glucose, kidney function)
TSH and T4
Additional Tests
- insulin (HOMA-IR) : a fasting insulin level which can indicate early insulin resistance
- testosterone
- cortisol
- vit D, B, folate and iron levels
- sleep study for sleep apnea
- liver/GB US or liver elastography
Treatment overview for obestiy
always focus on primary prevention early on, to prevent development
in overweight individuals and obesity wihtout comorbid = focus on preventing any comorbid conditions
in obese individuals with comorbid conditions = focus on preventing the conditions and the obestiy from getting any worse
in sum…
Lifestyle Changes
Medication
Surgery (bariatric)
a goal of lowering weight by 5-10% of TBW is enough to see significant chagnes and clincial improvement in the outcomes and risks of developing or progressing comorbid conditions
Behavior Health Interventions for Obesity
Sleep
Stressors
Sleep
- aim for 7-9 hours nightly
- poor sleep increases an individuals risk of obestiy by 15% is they sleep less that 5 hours
- asses their sleep: send for sleep studies to dx. OSA, stop-bang questionaire can help
Poor Sleep assocaited with
- increased cortisol, grhelin (hunger), inflammatory markers
- decreased leptin (full cue), insulin sensitivity, energy, mood and motivation
Stress
- focus on securing the base of maslos hierarchy: with phsyciological, safety and beloning/frienship needs
always assess their willingness to change and stage of change before initiating management
Behavioral Health Intervention for Obesity
Nutrition
Exercise
Nutrition
- SAD: standard american diet is POOR
- limit starches, sugars and carbs which will falsely trigger a quick blood sugar spike with a crash
- want to focuse on stopping the spike and crash pattern
- the spike and crash: leads to insulin increased rapidly, storage into fats & then the crash of hungry, moody, tired, shaky, dizzy, etc.
Counceling Tips
- cut back on SSB & ultra processed foods and alcohol
- cut back on starches and simple sugars
- focus on protein, non-starch fiber & veggies with healthy fats
- plan meals, avoid mindless and bedtime eating
Exercise
- not soley for weight loss but improves energy and mood!!
- increase NEAT: aka stand more
- incorportate strength straining, pick a workout that you enjoy and will follow
Benefits of exercise
- improve energy and sleep and mood
- help prevent disease processes
- improve mobility, pain and strength
Recommendations
- at least 150-300 minutes od moderate intensity aerobic activity/weekly
- or 75-150 of vigerous activity
- 2+ days of strength training
always ensure the nutrtion adn exercise goals are SMART
Anti-Obesity Medications (AOM) overview information
indicated for BMI > 30 OR BMI > 27 with comorbid conditions (GERD, HTN, lipids, DM)
all cannot be used in pregnancy (except metformin can be)
result in weight loss 5% or more
FDA approved for long-term weight management (except phentermine)
SAxenda, Wegovy and Orlistat are approved for ages 12+
Medications for Obesity (AOM)
GLP-1 Agonists
MOA: aid in the glucose metabolism; delay gastric emptying and help regular appetite
ADE: nausea, reflux, dirrhea, constipation HA (these are usually transient)
Caution
- pancreatitis risk
- active GB disease
- family or personal hx. of MEN
Names
- semaglutide (Wegovy) (for OBESITY)
- liraglutide (Saxeda) (for OBESTIY)
- other drugs (ozempic, etc.) are in the class, but only approved for T2DM
Medication for Obestiy (AOM)
Metformin
MOA: antidiabetic med; but decreases the hepatic glucose production, decreases absorbtion of glucose and increased peripheral uptake
ADR: vit B12, nausea, flatulence, dyspepsia, frequent/loss stools (transient)
taken with meals can help decrease this risk
Contraindications
- severe CKD with GFR < 30
- hepatic impairment (lactic acidosis risk)
Obesity Medications (AOM)
Phentermine
Phentermine
MOA: a norepinephrine releasing agent: triggering the stimulation pathway: therefore suppressing the hedonic pathways of the “feel good”
ADR: (its a stimulant like med so)
- increased heart rate
- anxiety
- insomnia
Caution
- only for those with controlled HTN; uncontrolled dont use
- arrythmias
- anxiety
approved for short term use of weight loss
Obesity Medication (AOM)
Phentermine/toperimate ER
Phentermine ( stimulant med) + topieramate
MOA: the NE-releasing agent + a GABA receptor modulator which acts as an appetite suppressant
ADR: increase HR, anxiety and insomnia + depression, teratogenic!!!!!! need regular pregnancy tests
Caution
- glaucoma pt.
- arrythima
- anxiety
- seizure disorders
- nephrolithiasis (screen prior to administration)
