Obesity Flashcards
What is obesity?
Accumulation of excess and abnormal body fat (adiposity)
Obesity is a (acute/chronic) condition that is ______________ and _____________.
Chronic
Progressive
Relapsing
What BMI used to be defined as obese? Why do we no longer rely only on this measurement?
BMI ≥30 kg/m2
- Underestimates the effects of excess body weight on health
- doesn’t take into account weight distribution and ectopic adiposity
In addition to BMI, what other marker do we now use to measure cardiometabolic risk?
Waist circumference
Even with BMI and waist circumference, what limitations still exist with this system of calculating cardiometabolic health?
- System was created using data from White European males (racial differences)
- Less accurate for those have not reached full growth
- Lean or muscular adults
- Adults 65+
What’s a better classification tool for obesity?
Edmonton Obesity Staging System
What BMI is considered underweight, normal, and overweight?
Underweight <18.5
Normal/Healthy 18.5-24.9
Overweight= 25.0-29.9
BMI 30 is when obese starts
What are the classes of obesity?
What are corresponding BMIs?
Class 1= 30-34.9
Class 2= 35-39.9
Class 3= 40-49.9
Class 4= 50-59.9
Class 5= ≥60
What are root drivers of weight gain?
4M Framework
- Mechanical
- Mental
- Metabolic
- and/or social Milieu
What medication classes are associated with weight gain?
- TCA
- Mirtazapine
- Tamoxifen
- First gen antipsychotics
- Second gen antipsychotics
- Dexamethasone
- Prednisone
- Hormones
- Insulin
- Meglitinides
- Sulfonylureas
- Thiazolidinediones
- Lithium (Mania)
- Flunarizine (Migraine)
- Pizotifen (Migraine)
- Valproic acid (Seizures)
- Carbamazepine (Seizures)
What are antidepressant alternatives that do not cause weight gain?
Bupropion
Fluoxetine
Sertraline
What antipsychotic alternatives do not cause weight gain?
Aripiprazole
Ziprasidone
What contraception method alternative would not cause weight gain?
Barrier methods
Copper IUD
What diabetes medication alternative would not cause weight gain?
Acarbose
Metformin
DPP-4 inhibitor
GLP-1 receptor agonists
SGLT2 inhibitor
What seizure medication alternative would not cause weight gain?
Topiramate
Lamotrigine
Is there a cure for obesity?
No
Successful management of obesity involves a long-term “________” strategy that allows patient to reduce body weight and prevent weight gain. There are intermittent periods of ___________ and ___________, commonly referred to as “_________ __________”
coping
remission and relapse
weight cycling
What are Obesity Canada’s 5As of obesity management?
- Ask
- Ask permission to discuss weight - Assess
- Assess BMI, waist circumference, obesity stage, and causes - Advise
- Discuss health risks, benefits, and treatment options - Agree
- Agree on realistic weight loss targets - Assist
- Assist in addressing barriers and follow/up
What non-pharm should we avoid?
Avoiding simplistic counselling approaches like “eat less, move more”
What non-pharm is our backbone therapy?
Multicomponent behavioural interventions like:
- Healthy food choices
- Increased physical activity
When adjusting patient’s diet, what are some things to keep in mind?
- Safety
- Efficacy
- Nutritional adequacy
- Culturally acceptable
- Affordable
What does the evidence say about short-term and long-term calorie-restricted diet?
Short term= comparable and significant weight loss if adherent
Long term= efficacy and safety not established.
What’s one thing we have to watch out for if calorie restricting our patients?
Associated with neurobiological pathway changes that favour increased food intake and weight gain.
Is exercise alone an effective strategy for weight loss?
No. More effective if combined with pharmacotherapy or diet.
How does physical activity benefit patient?
- Reduces cardiometabolic risk
- Enhances patient’s sense of well-being
- Promote weight maintenance
- Reduce insulin resistance
- Reduce loss of bone mineral density
Patient’s fitness level should be assessed prior to starting exercise program. When is a treadmill stress test considered?
Individuals with elevated CV risk
What exercise regimen can we recommend to patients?
Spend ≥30 minutes doing continuous or intermittent physical activity at least 5 days each week
What type of training can help build lean body mass and sustain weight loss in the long term?
Resistance training
What type of exercise can improve cardiorespiratory fitness?
High-intensity interval training
What the three primary interventions (3 pillars of support) that can be used alongside our mainstay behavioural interventions?
- Bariatric surgery
- Pharmacotherapy
- Psychological intervention
What are the two types of psychological interventions?
CBT
Acceptance and Commitment Therapy
When should bariatric surgery be considered?
Severe obesity (stage 2 with comorbidities or higher)
OR
Moderate obesity and at least 1 obesity related comorbidity
OR
Attempted nonsurgical weight loss
What are complications of bariatric surgery?
GI obstruction
Surgical site infections
Incisional hernia
What are relative contraindications for bariatric surgery?
- Severe HF
- Unstable coronary artery disease
- End-stage lunge disease
- Active cancer diagnosis/treatment
- cirrhosis with portal hypertension
- Crohn’s disease
- Uncontrolled drug or alcohol dependency
- Severely impaired intellectual capacity
What conditions can make bariatric surgery difficult or impossible?
- Giant ventral hernias
- Severe intra-abdominal adhesions
- Large liver
- Central obesity
- Physiological intolerance of pneumoperitoneum
What is an important counselling point for patients getting bariatric surgery?
Need for lifelong nutritional changes to avoid nutritional complications
All post-bariatric surgery patient should have routine screening for nutritional deficiencies
What’s a typical supplementation routine for most bariatric patients?
- 2 complete multivitamins per day
- Calcium
- Iron
- Vit B12
- Vit D
Which drugs should you avoid after bariatric surgery?
- GI irritants
- oral bisphosphonates
- NSAIDs - Drugs at high risk of hypoglycemia
- sulfonylureas
Another one of the three pillars is pharmacotherapy.
Combination of lifestyle modification and anti-obesity drug therapy is __________ to lifestyle modification alone.
Superior
What can happen if we discontinue antiobesity medications?
Weight regain
Meds should be continued as long as there is benefit
What are the four drug approved for weight loss?
- Orlistat
- Naltrexone/Bupropion
- Liraglutide (GLP-1)
- Semaglutide (GLP-1)
What is the mechanism of action with orlistat?
Pancreatic and gastric lipase inhibitor which reduces dietary fat absorption by 30%.
What is the doing for orlistat?
Orlistat 120mg TID
Orlistat is less effective in patients on (low/high)-fat diets?
Low
What type of diet can make orlistat therapy difficult to tolerate?
High-fat
- Increased evidence of GI s/e like bloating, steatorrhea, and oily discharge
What patient population is orlistat approved for?
Patients with obesity and type 2 diabetes
- improved glycemic and metabolic control
What’s the mechanism of action with naltrexone/bupropion?
Combo has synergistic effect and mediates hormones involved in appetite and reward in the hypothalamus
What’s the most common adverse effect with bupropion/naltrexone?
Transient nausea
What’s the typical dosing of natrexone/bupropion?
Bupropion/naltrexone 180/16mg BID
What patient population is naltrexone/bupropion approved for?
Adults with obesity/overweight with the presence of at least 1 weight-related comorbidity
What patient population should avoid bupropion/naltrexone (Contrave)?
- Uncontrolled hypertension
- Seizure disorder
- Severe hepatic or end-stage renal failure
What is the mechanism of action of GLP-1 agonists?
Stimulate insulin secretion
Reduce postprandial glucose levels
Slow gastric emptying
Reduce appetite
Final: weight reduction and blood glucose level reduction
What is the dosing for liraglutide and semaglutide?
Liraglutide 3mg SC daily
Semaglutide 2.4mg SC weekly
Which of the two GLP-1 agonists are superior for inducing weight loss?
Semaglutide
Does semaglutide and liraglutide have similar rates of adverse effects and safety profiles?
Yes
What is the use of GLP-1 agonists associated with an increased risk of? Is this a concern?
Pancreatitis
Bowel obstruction
Gastroparesis
*when compared with naltrexone/bupropion.
However, absolute risk of increase remains low
What is tirzepatide?
What is its mechanism of action?
Is it used in Canada for obesity?
Dual action glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptor agonist
MOA: in addition to GLP-1’s central effects, GIP will act peripherally by targeting adipose tissues
Not yet approved in Canada for treatment of obesity
What is the risk of obesity in pregnancy?
Gestational diabetes mellitus (GDM)
Gestational hypertension
Preeclampsia
Birth defects
C-section
Fetal macrosomia
Perinatal death
Postpartum anemia
Childhood obesity
What are complications of obesity in non-pregnant women?
Excessive weight gain at younger age is associated with earlier menarche and menstrual problems
Obesity is a strong risk factor for _________ ___________ __________.
Polycystic ovarian syndrome
Menstrual functioning, ovulation, and fertility improve with ________ ________.
Weight loss
Bariatric surgery for severe obesity has been associated with better outcomes in patient and child.
However, due to possibility of nutritional deficiency, patients who have undergone bariatric surgery are advised to delay pregnancy for __-__ years.
1-2 years
Given all the risks of associated with obesity in pregnancy, should we advise patient to lose weight during pregnancy?
No.
Recommended that they gain no more than 5-9.1kg or 11-20lbs.
Is pharmacotherapy for weight loss during pregnancy recommended?
No
___________ rates of breastfeeding may be associated with excess weight or obesity?
Decreased
This is concerning as breastfeeding has been associated with ___________ development of obesity later in life.
reduced
Which of the pharmacotherapies are ok for breastfeeding?
Orlistat= avoid due to nutritional deficiencies
Bupropion= small amounts are transferred and unlikely to cause side effect. However, two cases of seizures noted in breastfed infants
GLP-1= CI
What is a goal of therapy for weight loss therapy?
Reducing weight by 5-10%
