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Medical Study > Obesity > Flashcards

Obesity Flashcards

Learn basic weightloss management medicine and techniques

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USMLE® Step 1 flashcards
1
Q

Contrave (wellbutrin/naltrexone) dosing

A

90mg/8mg

Ramp up weekly 1 tab po qam, 1 tab po bid, 2 tabs qam and 1 po qpm, 2 tabs po bid

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2
Q

Contrave contraindications

A
  • seizure disorder
  • opiate use
  • uncontrolled HTN
  • within 14 days of MAOIs
  • caution is current alcohol or bzd use
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3
Q

Contrave actions

A

Good if food cravings and addictive behavior, depression, smoking cessation,
other substance cessation

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4
Q

Liraglutide (saxenda) dosing

A
  • GLP-1 agonist
  • 5-10% wt loss
    Victoza dose for dm2 only up to 1.8 mg
    Saxenda dose is 3 mg (studies haven’t been done to assess cardiovascular
    prevention)
    • Start at 0.6 mg and go up by 0.6 mg weekly up to 3 mg, but many
    people can’t always do the full titration due to SEs
    D/c if <4% body weight after 16 weeks at 3 mg
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5
Q

Liraglutide contraindications

A

pancreatitis, family or PH medullary thyroid cancer (MEN-2)

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6
Q

Lorcaserin dosing

A

No generic, so more costly

  • can get up to 10% wt loss
  • start 10 mg ER before dinner
  • 10 mg bid or 20 mg ER daily
  • stop if <5% wt loss at 12 wks
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7
Q

Lorcaserin SEs

A

HA, dizziness, fatigue, nausea, dry mouth, constipation

though SEs low with this medication

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8
Q

Lorcaserin contraindications

A
  • Theoretic risk of valvulopathy (prior seen in Phen-phen), but not same receptor
    affinity as lorcaserin
  • Risk for serotonergic over-activity, avoid prescribing with other serotonergic
    agents
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9
Q

Qysmia (phentermine/topamax) dosing

A
  • if dosing separately, give phentermine in AM and topamax 1 hr prior to dinner (helps with nighttime eating)
  • Start 3.75 for 2 weeks then 7.5 for 1 month, then may escalate up each
    month
    • 3.75 is considered acclimation dose, not the one that really achieves weight loss. Some may benefit from it as maintenance though
    • 7.5/46 is considered normal maintenance dose, most people achieve
    weight there. Higher doses are for people not losing weight
    ▪ Stop if not 5% weight loss after 12 weeks on maximum dose
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10
Q

Qysmia contraindications

A

uncontrolled HTN, CAD, glaucoma, nephrolithiasis,

insomnia, anxiety, okay if well-controlled HTN with close monitoring

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11
Q

Qysmia SEs

A

dry mouth, paresthesia, constipation, abn taste in mouth, insomnia, glaucoma
- metabolic acidosis
- elevated Cr
▪ Gradual escalation of doses, helps minimize SEs

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12
Q

Adult overweight

A

BMI 25-29.9

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13
Q

Adult class 1 obesity

A

BMI 30-34.9

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14
Q

Aduly class 2 obesity

A

BMI 35-39.9

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15
Q

Adult morbid obesity, class 3

A

Bmi>/=40

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16
Q

Pediatrics overweight

A

BMI 85th-95th%

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17
Q

Pediatric class 1 obesity

A

BMI 95th-120th%

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18
Q

Pediatric class 2 obesity

A

BMI 120th-140th%

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19
Q

Pediatric class 3 obesity

A

BMI >140th%

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20
Q

Obesity definition

A

chronic, progressive, relapsing, multi-factorial neurobehavioral dz causing inc adiposity leading to metabolic and psychosocial health consequences

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21
Q

Adiposopathy/Sick fat disease

A

pathogenic adipose tissue causing endocrine and immune dysfunction

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22
Q

Fat mass disease

A

Pathogenic forces from excessive body fat cause stress damage on body

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23
Q

Functional foods definition

A

Nutrients with potentially favorable effects outside of basic nutrition (ie complex carbs provide heart health)

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24
Q

Non-obesity causes DM2

A
  • hemochromatosis
  • hypercortisolism
  • excessive growth hormone
  • pancreatic insufficiency
  • SE of medication
  • genetic syndromes
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25
Q

Non-obesity causes HTN

A
  • pheo
  • primary hyperaldosteronism
  • hypercortisolism
  • hyperthyroidism
  • RAS
  • CKD
  • SE of meds
  • genetic syndrome
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26
Q

Non-obesity causes dyslipidemia

A
  • Hypothyroidism
  • poorly controlled DM2
  • liver dz
  • CKD
  • SE of medication
  • Genetic dyslipidemia
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27
Q

Mech of obesity, insulin resistance, and metabolic dz

A

Positive caloric balance and adiposopathy–> inc free fatty acids (FFA)–> fat deposition in liver and muscles–> dysfunction, inc insulin resistance–> hyperinsulinemia, pancreas dysfunction, inc BG, HTN, dyslipidemia, CAD, CA–> worsens obesity and adiposopathy

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28
Q

1st major organ affected by adipose deposition

A
  • often the liver
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29
Q

Body fat distribution

A
  • pericardial
  • intracardial
  • Visceral
  • Hepatic and skeletal m fat
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30
Q

CVD outcomes and anti-obesity medications

A

No AOM proven to improve cardiac outcomes

- GLP1 do help in DM2, studies being done with obesity

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31
Q

locarsarin health benefits

A
  • may help dec rate of DM2 or rate/progression of CKD
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32
Q

Medication for obesity with CVD

A
  • nutrition/exercise

- no medications are really contraindicated in CVD

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33
Q

Semaglutide

A
  • used to tx DM2, SE of weight loss
  • PIONEER trial looking at oral administration
  • SELECT trial looking at CVD prevention in obesity
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34
Q

Most common M&M in obesity

A

CVD

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35
Q

patient first language

A

Pt who is overweight or obese preferred over “obese patient”

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36
Q

Obesity as multifactorial disease

A

Involves:

  • genetics/epigenetics
  • neurobehavioral
  • medical
  • endocrine
  • environment (social/culture)
  • immune
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37
Q

Extragenetic causes obesity

A
  • environment (family, geography)
  • culture
  • poor nutrition/PA
  • disrupted sleep (too little or too much)
  • medication SEs
  • stress
  • neurologic dysfunction
  • viral infections
  • gut microbiota, pro-inflammatory state
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38
Q

Epigenetics definition

A

Alteration in gene expression without alteration in genetic code
- occurs pre-pregnancy, intrautero, and post-pregnancy

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39
Q

Pre-pregnancy epigenetics

A

Pre-conception weight of both parents can influence signalling in pregnancy

  • inc risk overwt/obese children
  • inc risk CAD, CA, DM, etc in children
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40
Q

Pregnancy epigenetics

A

GDM and poor maternal nutrition, overwt/obese increases nutrient transfer to fetus (glucose, aa, lipids, FA)

  • both under weight and overweight inc risk of obesity
  • smoking and stress inc risk
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41
Q

Result of inc nutrient transmission to fetus

A
  • modifications in gene expression
  • change in stem cell fate
  • Alter postnatal substrate metabolism
  • inc risk for overwt, obesity
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42
Q

Sick fat disease

A

Adiposopathy

  • inc BG
  • HTN
  • HLD
  • other metabolic dz
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43
Q

Fat mass disease

A
  • stress on joints
  • immobility
  • tissue compression (OSA, GERD, HTN)
  • tissue friction (intertrigo, etc)
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44
Q

Overall management goals for obesity

A
  • improve overall health
  • improve QOL
  • improve BW and composition
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45
Q

Essential fat values

A

women 10-13%

men 2-5%

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46
Q

athlete fat values

A

women 14-20%

men 6-13%

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47
Q

fitness fat values

A

women 21-24%

men 14-17%

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48
Q

acceptable fat values

A

women 25-31%

men 18-24%

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49
Q

obesity fat values

A

women >/=32%

men >/=25%

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50
Q

Abdominal obesity men

A

> /=40 inches

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51
Q

abd obesity women

A

> /= 35 inches

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52
Q

abd obesity asians

A

women >/= 31.5

men >/=36

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53
Q

Codes for obesity

A
  • Code first if obesity complicating pregnancy, etc, then BMI code
  • E66- overweight/obesity and specify type
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54
Q

Best measure of obesity

A
  • BMI is good screening measure
  • WC helps to determine weight distribution and worse metabolic outcomes
  • %BF good to look at extremes of m mass (ie sarcopenia or inc m mass) that may skew BMI number
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55
Q

Cardiovascular fat mass dz

A
  • CHF, cor pulmonale
  • HPfEF
  • Varicose veins
  • DVT, PE, CVA
  • HTN
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56
Q

Pulmonary fat mass dz

A
  • Dyspnea
  • OSA
  • Hypoventilation syndrome
  • Asthma
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57
Q

Neurologic fat mass dz

A
  • Intracranial HTN (psueudotumor cerebri)
  • CVA
  • n entrapment
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58
Q

MSK fat mass dz

A
  • immobility
  • arthritis
  • back pain
  • myalgias
  • impaired balance
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59
Q

GI fat mass dz

A
  • GERD

- hernias

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60
Q

Integument fat mass dz

A
  • striae (stretch marks)
  • stasis pigmentation
  • venous stasis ulcers
  • skin tags
  • intertrigo
  • carbuncles
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61
Q

Metabolic manifestations adiposopathy

A
  • inc BG
  • HTN
  • metabolic syndrome
  • HLD
  • fatty liver
  • hyperuricemia/gout
  • cholelithiasis
  • acanthosis nigricans
  • nephrolithiasis
  • glomerulonephropathy
  • neuropsych dz
  • asthma
  • OA
  • CAD
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62
Q

adiposopathic dyslipidemia

A
  • inc TG
  • low HDL
  • inc apolipoprotein B (atherogenic prot)
  • inc LDL
  • inc lipoprotein remnants
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63
Q

Female issues adiposopathy including pregnancy

A
  • hyperandrogenism
  • hirsutism
  • acne
  • PCOS
  • infertility
  • menstrual irregularities
  • GDM
  • PreE
  • thrombosis
  • inc risk miscarriage or stillbirth
  • inc need for IOL
  • inc risk with C/s healing and infection
  • LGA babies
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64
Q

Male issues adiposopathy

A
  • hypoandrogenemia
  • hyperestrogenism
  • ED
  • low sperm count
  • infertility
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65
Q

Obesity associated CA

A
  • bladder
  • brain
  • breast
  • cervical
  • colon
  • uterine
  • GB
  • esophageal
  • renal
  • leukemia
  • liver
  • MM
  • non-hodgkin lymphoma
  • ovarian
  • pancreatic
  • prostate (prognosis is worse)
  • stomach
  • thyroid
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66
Q

Emergent fight/flight response

A

Occurs in time of acute stress, inc sympathetic activity:

  • inc catecholamines (E, NE)
  • inc BP
  • vasoconstriction
  • inc HR and contractility
  • dec blood flow to kidneys
  • bronchial dilation
  • inc in glucose levels
  • inc adipose tissue lipolysis
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67
Q

Endocrine response to chronic stress

A

Submit and stay response by hypothalamic pituitary axis activity:

  • inc corticotropin-rel horm
  • inc adrenocorticotropin
  • inc arginine, vasopressin, and oxytocin
  • inc cortisol
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68
Q

response to inc cortisol

A
  • inc BG
  • inc BP
  • inc food cravings
  • inc adipose tissue lipolysis and m tissue wasting
  • inc accumulation of abd fat
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69
Q

Immune response to acute stress

A

catecholamine mediated:

  • enhance immune sys
  • demarginalization WBC
  • inc adaptive immune response and T cell activity
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70
Q

immune response to chronic stress

A

Glucocorticoid mediated

  • dysregulation of immune sys
  • inc total WBC with inc systemic inflammation
  • dec immune resp and T cell activation
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71
Q

Chronic stress and eating behaviors

A

Affects limbic system (thalamus, hypothalamus, amydala, and hippocampus) and cerebrum
- enhances desire for hyperpalatable foods

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72
Q

Adiposopathy stress cycle

A
  • Become obese and metabolic dz
  • cause chronic stress
  • leads to behavior change, endocrinopathy, and immunopathy
  • leads to inc body fat
  • worsening adipose tissue dysfunction
  • which leads to more obesity and metabolic dz causing a cycle
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73
Q

history for obesity visit

A
  • screen for fat mass dz
  • screen for adiposopathy dz (DM2, HTN, etc)
  • eating disorder screen
  • mental stress
  • sleep
  • medications associated with weight gain
  • smoking
  • alcohol
  • drugs
  • weight pattern over lifetime
  • previous attempts to lose weight, barriers or successes
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74
Q

FH for obesity visits

A
  • other obese family members

- Medical dz related to obesity

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75
Q

SH for obesity visits

A
  • availability of healthy food- who buys
  • access to physical activity
  • economic status
  • social status
  • culture
  • occupation
  • family structure
  • living situation
  • abuse
  • geographic location
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76
Q

Nutritional hx for obesity visits

A
  • timing and frequency of meals
  • where do they eat meals
  • location of away food consumption
  • access to foods
  • preparer of foods
  • nutritional content
  • triggers for eating
  • nighttime eating activities
  • binge eating/emotional eating
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77
Q

Physical activity history

A
  • success/failures for previous attempts
  • barriers to previous attempts or engaging now
  • current PA (FITTE)- frequency, intensity, time of duration, type, enjoyment
  • current fitness level and mobility
  • equipment needs
  • access to locations
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78
Q

VS/weight measure for obesity visit

A
  • Ht/Wt
  • BMI
  • waist circumference (using superior iliac crest)
  • BP
  • Pulse
  • neck circumference
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79
Q

Routine lab testing at obesity visit

A
  • fasting BG
  • A1c
  • lipids
  • LFTs
  • BMP
  • uric acid?
  • TSH
  • Vit D
  • CBC
  • UA, urine micro/Cr
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80
Q

Individualized labs in obesity

A

Based on suspected 2/2 causes

  • glucose tolerance testing
  • fasting insulin, proinsulin, and C peptide
  • Dexamethasone suppression test
  • midnight salivary cortisol
  • prolactin, estradiol, FSH, LH, preg test
  • Testosterone, DHEA-S
  • apolipoprotein B
  • iron studies
  • CRP
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81
Q

Individualized imaging in obesity

A
  • MRI or CT brain
  • EKG
  • stress test
  • echo
  • ABI
  • sleep study
  • liver u/s
  • resting metabolic rate
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82
Q

Ways to test body composition

A
  • DEXA
  • bioelectric impedence
  • whole body air displacement plethysmography
  • myotape
  • caliper % body fat
  • underwater weighing
  • quantitative MR
  • CT
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83
Q

Emerging tests for obesity

A
  • leptin
  • leptin-adiponectin ratio
  • FFA
  • TNF
  • IL 1 and 6
  • gut microbiota
  • adenovirus assays
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84
Q

fat free mass

A

total body mass minus any body fat

- includes water, mineral, prot, and glycogen

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85
Q

Lean body mass

A

total body mass minus non-essential or storage adipose tissue
- includes water, mineral, protein, glycogen, essential fat in organs, CNS, and bone marrow

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86
Q

Difference between fat free and lean body mass

A

differs only by about 5%

  • little less in men
  • little more in women
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87
Q

TBM calculation

A

= fat mass + lean mass + bone mass

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88
Q

Lean mass calculation

A

= total mass - fat mass- BMC

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89
Q

% body fat calculation

A

= fat mass/ (total body mass-bone mass)

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90
Q

Calipers to measure body fat

A
  • user dependent, results can vary widely

- not optimal if very high BMI

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91
Q

DEXA to measure body fat

A
  • accurate
  • relatively inexpensive
  • not all differentiate visceral vs SC fat
  • not all accomodate very high BMI in machine
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92
Q

Gold standard for body fat composition measure

A
  • DEXA

- gives % body fat, android fat (SC and visceral), lean body mass, and BMD

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93
Q

Total energy expenditure

A

In mod physical inactivity people:

  • 70% resting metabolic rate
  • 20% physical activity
  • 10% diet induced thermogenesis
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94
Q

Meds that can inc body weight

A
  • beta-blockers (propranolol, atenolol, metoprolol)
  • CCB- nifedipine, amlodipine, felodipine
  • insulin
  • SUs
  • TZDs
  • meglitinides
  • steroids
  • E
  • progestins (injectables have greatest risk)
  • Testosterone
  • carbamazepine
  • gabapentin
  • depakote
  • lyrica
  • TCAs
  • doxepin
  • lithium
  • antipsychotics
  • benadryl
  • aromatase inhibitors
  • tamoxifen
  • methotrexate
  • SSRIs- paxil, celexa, lexapro (variable), zoloft (variable)
  • SNRIs- duloxetine, venlafaxine
  • mirtazipine
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95
Q

DM Meds that can dec body weight

A
  • metformin
  • GLP1 agonists
  • SGLT-2 inhibitors
  • alpha glucosidase inhibitors
  • pramlinitide
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96
Q

Anti-seizure meds that may dec weight

A
  • lamictal
  • topamax
  • zonisamide
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97
Q

Antidepressants that may dec weight

A
  • wellbutrin
  • prozac (variable)
  • nortriptyline has no weight change
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98
Q

carbohydrates general

A
  • contain 4 kcal/g
  • source of energy and used for cellular structure
  • non-essential since liver can synthesize glucose
  • broken down into monosaccharides
  • may contain sugar, starch, and fiber
  • no known carbohydrate def dz
  • DRI for carbs is 130 g/day
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99
Q

Fat general

A
  • contains 9 kcal/g
  • used as energy source for immune response, cell membrane structure, brain tiss, synthesis of bile acid, cholesterol, vit D, and hormones, insulation
  • need essential fatty acids that body cannot synthesize
  • DRI at least 30 g/day
  • replacing saturated with polyunsaturated or monounsaturated dec cardiovascular risk
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100
Q

Protein general

A
  • contains 4 kcal/g
  • contain AA and are major structural building block in body
  • essential AA cannot be made by the body and must be consumed
  • some used as energy source (made to glucose and ketones)
  • def leads to kwashiorkor
  • DRI 0.8-2g/kg/d
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101
Q

Insulin affect on body

A
  • promotes FA and TG synthesis (lipogenesis) and storage
  • inhibits fat breakdown (lipolysis)
  • limiting foods that stimulate rise in insulin helps promote weight loss
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102
Q

Very low-calorie diet

A

<800 cal/day

  • requires close medical supervision for safety
  • recommended for short duration
  • utilize full meal replacements to make sure getting all essential nutrients in the caloric intake
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103
Q

Low calorie diets

A
  • women 1200-1500

- men 1500-1800

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104
Q

Fat restriction and cholesterol

A

More reduction in total cholesterol and LDL

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105
Q

Carb restriction and cholesterol

A

More reduction in TG and inc in HDL

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106
Q

Types restricted fat diets

A
  • low fat diet

- very low fat diet

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107
Q

low fat diet definition

A

<30% fat calories

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108
Q

very low fat diet definition

A

<10% fat calories

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109
Q

types restricted carb diets

A
  • low glycemic diet
  • low carb diet
  • very low carb diet
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110
Q

Low carb diet definition

A

50-150 g/day

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111
Q

Very low carb diet definition

A

<50 g/d with or without nutritional ketosis

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112
Q

Low carb diet weight loss

A
  • modestly greater wt loss than fat restricted by 6 mths, then after is similar
  • may help with food cravings
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113
Q

low carb diet metabolic effects

A

Effects can occur with or without wt loss

  • dec fasting gluc and TG
  • Inc HDL
  • Inc LDL
  • Dec BP
  • may help dec DM complications (ie neuropathy)
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114
Q

Risks low carb diet

A
  • May cause inc carb cravings during first fe w days
  • inc gout flares
  • malaise
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115
Q

Wt loss low fat diet

A
  • after 6 mths same as carb restriction
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116
Q

Metabolic effects low fat diet

A
  • dec glucose and insulin
    dec LDL
  • dec BP
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117
Q

Risks low fat diet

A
  • hunger control can be challenge

- may substitute higher carb foods which can lead to hyperglycemia and inc cholesterol

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118
Q

Wt loss very low calorie diet

A
  • rapid weight loss
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119
Q

Metabolic effects very low calorie diet

A
  • dec gluc, TG, LDL
  • inc HDL
  • Dec BP
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120
Q

Risks very low calorie diet

A
  • fatigue, nausea, constipation, diarrhea, brittle nails
  • cold intolerance
  • dysmenorrhea
  • sm inc GB and kidney stones, gout flares
  • cardiac dysrhythmias, m cramps
  • wt regain will occur if not transitioned proprerly
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121
Q

Trans fats

A
  • artificially created to inc melting temps of fast
  • inc LDL, dec HDL
  • inc cardiac dz, DM and CA
  • FDA has banned them, but can still be found in some products
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122
Q

Mediterranean diet

A

Describes meal patterns seen in Greece, Italy, and Spain

  • dec cardiac risk
  • olive oils
  • veggies, fruits
  • legumes, nuts, seeds
  • whole grains
  • mod intake red wine
  • mod consumption seafood, fermented dairy products (cheese, yogurt), chicken, and eggs
  • limits red meat and sweets
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123
Q

Therapeutic lifestyle diet

A

Low fat meal plan, used most in lipid trials

  • total fat 25-35% daily calories
  • polyunsaturated fat up to 10%
  • carbs 50-60%
  • 5-10 g fiber/day
  • 2 g/day plant stanols or sterols
  • avoid trans fat and limit saturated fat to <7%
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124
Q

Ketogenic diet

A

Carb restricted diet, promotes using fat for energy and making ketosis

  • induction phase: <20 g carbs/d from non-starchy veggies, adequate protein, and inc fat
  • weight loss phase: allows more variety of veggies, seeds, and nuts and low-glycemic fruits
  • premaintenance phase: carb intake slowly inc
  • maintenance phase: 60-90 g carbs/d
  • avoid processed and refined foods and trans fat
  • most phases limit grain carbs, dairy (except cheese), starchy veggies, and most fruits
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125
Q

Ornish diet

A

fat restriction diet

  • encourages foods in natural form
  • 1 serving soy product/d
  • limited amts green tea
  • fish oil each day
  • small frequent meals
  • avoid sugar, sodium, alcohol, meat, caffeine, trans fats, refined carbs
  • limit fat <10%/d
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126
Q

DASH diet

A

Used for cardiac and HTN

  • encourage fruits/veggies, and whole grains
  • fat free dairy products
  • fish, chicken, and lean meats
  • nuts, seeds, legumes
  • fiber, Ca, Mg, K
  • limit Na to 1500-2300 mg/d
  • limit fat <27%
  • limit saturated fat <6%
  • avoid red meat, sugary foods and beverages
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127
Q

Paleolithic diet

A

Based on diet pattern from paleolithic period

  • encourage veggies, fruits, and root veggies
  • lean red meat, seafood
  • eggs, nuts, seeds
  • healthy oils
  • Avoid grains, potatoes, processed foods, refined sugars and oils, legumes. dairy
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128
Q

Vegan

A
  • only plant based foods, no animal proteins or products (eggs, milk, honey)
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129
Q

Lacto-vegetarian

A

plant foods plus dairy

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130
Q

lacto-ovo vegetarian

A

plant foods, dairy, and eggs

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131
Q

pescatarian

A

plants and seafood

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132
Q

Advantages intermittent fasting

A
  • helps dec decision making about food
  • can fit better in schedule
  • dec calories but preserves lean body mass
  • lose weight and improve metabolic outcomes
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133
Q

Disadvantages intermittent fasting

A
  • doesn’t emphasize healthy eating
  • not good if eating disorder
  • may not be sustainable
  • inc risk hypoglycemia in DM
  • may inc gout, nephrolithiasis, and dysrhythmias
  • lot of long-term studies based on animal models
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134
Q

Physical activity and adiposopathy

A
  • helps with weight loss and maintenance
  • improves adiposopathic psychological problems
  • inc insulin sensitivity
  • inc mitochondrial function
  • inc browning of fat cells
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135
Q

PA for those unable to walk

A
  • chair exercises
  • arms with cycling or bands
  • swimming/acquatic
  • gravity mediated
  • PT
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136
Q

PA for limited mobility

A
  • walking
  • swimming/aquatic
  • gravity mediated
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137
Q

Dynamic/aerobic PA and wt loss

A

Recommend 150 min/wk mod intensity or 75 min high intensity

- >300 min mod or 150 high leads to more wt loss and dec regain

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138
Q

Types physical activity

A
  • dynamic/aerobic
  • resistive strength/anaerobic
  • leisure activities
  • NEAT (non-exercise activity of transportation)
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139
Q

Exercise prescription

A

FITTE

  • frequency
  • intensity
  • time spent
  • type
  • enjoyment
  • may add volume of exercise and progression
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140
Q

Stages of change

A
  • precontemplation
  • contemplation
  • preparation
  • action
  • relapse
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141
Q

focus of MI

A
  • collaborate to find and implement solutions
  • evoke patients’ feelings and ideas
  • autonomy- empower pts to own their solution
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142
Q

principles of MI

A
  • express empathy
  • avoid argumentation
  • develop discrepancy
  • resolve ambivalence
  • support self-efficacy
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143
Q

5 As of obesity management

A
  • Ask
  • Assess
  • Advise
  • Agree
  • Arrange/assist
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144
Q

Ask 5As

A
  • ask permission to discuss weight

- explore readiness

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145
Q

Assess 5As

A
  • look at BMI, WC

- explore drivers and complications of excess weight

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146
Q

Advise 5As

A
  • talk about health risks and benefits of modest wt loss (5-10%), and tx options
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147
Q

Agree 5As

A
  • set realistic expectations for wt loss, behavior changes, goals, and tx plan
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148
Q

Arrange/assist 5As

A
  • identify and address barriers
  • give resources
  • arrange f/u
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149
Q

Why do people eat too much

A
  • biologic forces resisting wt loss and promoting wt gain
  • hypothalamic dysfunction
  • hunger before meals
  • lack satiety after meals
  • triggers in environment
  • eating as reward
  • feeling obligation
  • advertising
  • lack of knowledge
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150
Q

Binge eating disorder

A
  • episodes of eating large amounts of food >1x/wk for at least 3 mths
  • no purging
  • feels lack of self control, shame, and guilt
  • 2-3% of adults
  • most common eating disorder
  • Eating attitudes test can help diagnose
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151
Q

Tx binge eating disorder

A
  • CBT
  • lisdexamfetamine
  • non-FDA approved: SSRIs, topomax
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152
Q

Bulimia Nervosa

A
  • cycle of recurrent binge eating and purging
  • 1% adults
  • can have hypoK, hypoMg
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153
Q

russell sign

A

calluses and abrasions on dorsum of hands due to repeated contact with teeth in purging

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154
Q

Tx bulimia

A
  • prozac

- non-FDA: topamax, naltrexone

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155
Q

night-eating syndrome

A
  • at least 25% of daily food consumed after evening meal
  • waken from sleep and eat to get back to sleep
  • often carb rich snacks
  • little interest in breakfast
  • 5% population
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156
Q

Why do people regain bodyweight

A
  • body strongly resists undernutrition
  • wt loss decreases leptin, insulin, cholecystokinin, and peptide YY which increases appetite
  • wt loss cause inc ghrelin which increases appetite
  • exercise may inc sensitivity to insulin and leptin
  • lack of maintenance of PA
  • dec resting energy expenditure
  • greater m efficiency, so less resting expenditure
  • people go back to previous habits or lack of PA
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157
Q

BMI requirement for obesity medications

A
  • BMI >30

- BMI >27 with co-morbidities

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158
Q

When non-responder

A

<4-5% wt loss on maximum therapy for 12-16 weeks depending on medication

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159
Q

Wt loss expected with AOM

A

5-10%

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160
Q

phentermine

A
  • sympathomimetic amine
  • approved for short-term use (12 weeks)
  • 5% weight loss
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161
Q

phentermine SE

A
  • HA
  • HTN
  • arrhythmia
  • tremor
  • insomnia
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162
Q

phentermine contraindications

A
  • uncontrolled BP
  • seizure d/o
  • h/o CAD
  • within 14 days of MAOIs
  • glaucoma
  • drug abuse
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163
Q

Orlistat

A
  • GI lipase inhibitor, impairs digestion of fats
  • OTC
  • 5% wt loss
  • dosing 120 mg tid qAC
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164
Q

Orlistat SEs

A
  • oily leaking
  • flatus
  • inc gallstones or kidney stones
  • malabsorption fat soluble vitamins (beta carotene, vit K, A, D, E)
  • rare iiver injury and pancreatitis
  • Recommend taking MTV to prevent deficiencies
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165
Q

Orlistat med interations

A
  • cyclosporine
  • OCPs
  • seizure meds
  • thyroid meds
  • warfarin
  • Vit K levels tend to decline
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166
Q

lorcaserin

A
  • 5HTP 2c rec agonist
  • helps with sense of fullness
  • 5-10% loss
  • dose 10 mg bid for IR or 20 mg qd for ER
  • metabolized in liver and excreted in urine
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167
Q

lorcarserin SEs

A
  • HA
  • dizziness
  • fagitue
  • nausea
  • confusion
  • euphoria/dissociation
  • priapism
  • bradycardia
  • leukopenia/anemia (monitor CBC periodically)
  • dry mouth
  • constipation
  • risk serotonin syndrome, NMS, heart failure, psych disorders, and priapism
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168
Q

lorcaserin drug interactions

A
  • SSRIs
  • SNRIs
  • MAOIs
  • anti-dopaminergic meds
  • St. John’s Wort
  • triptans
  • buproprion
  • dextromethorphan
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169
Q

liraglutide SEs

A
  • nausea, dyspepsia
  • hypoglycemia
  • diarrhea, constipation, vomiting
  • HA
  • dec appetite
  • fatigue, dizziness
  • CKD
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170
Q

Liraglutide contraindications

A
  • MEN type 2
  • medullary thyroid CA or FH of
  • pancreatitis
  • GB disease
  • SI
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171
Q

Naltrexone SEs

A
  • nausea, constipation, HA, vomiting, hepatitis and liver failure, dizziness, insomnia, dry mouth, diarrhea, glaucoma
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172
Q

Contrave drug interactions

A
  • opiates
  • seizure meds
  • MAOs
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173
Q

Qysmia drug interactions

A
  • MAOIs

- may alter OCP absorption

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174
Q

supplement definition

A
  • substances taken in addition to dietary intake
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175
Q

function food definition

A
  • nutrients in foods with potentially favorable effects beyond nutrition
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176
Q

Hepatotoxicity related to supplements

A
  • account for 20% of cases of hepatotoxicity

- common causes are anabolic steroids and green tea extract

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177
Q

How does obesity cause high BP

A
  • sleep apnea
  • renal vessel compression
  • perivascular adipose tissue
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178
Q

Sleep apnea and inc BP

A
  • cardiac press overload due to frequent changes in thoracic pressure
  • inc cardiac o/p due to hypoxia
  • inc cardiovascular inflammation
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179
Q

Renal vessel compression and HTN

A
  • inc abd pressure due to fat
  • restricted vessel expansion
  • impaired naturesis
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180
Q

NAFLD

A
  • most common cause chronic liver disease
  • 45% hispanic
  • 33% caucasians
  • 24% blacks
  • more than 2/3 have obesity
  • 30% of pts with NAFLD progress to inflammation NASH
  • leads to cirrhosis and inc risk for HCC
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181
Q

Medications that can inc NAFLD

A
  • steroids
  • HAART
  • amiodarone
  • tamoxifen
  • methotrexate
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182
Q

2/2 NAFLD

A
  • excessive, rapid weight loss
  • starvation
  • TPN
  • hep C infection
  • environmental toxicity
  • wilsons dz
  • celiac dz
  • lipodystrophy
  • disorders of lipid metabolism
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183
Q

Tx NAFLD

A
  • weight loss and diet

- no meds approved, but metformin, GLP1 agonists, and vit E may help

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184
Q

How obesity causes CA

A
  • release of cytokines
  • inc CA promoting hormones
  • inc insulin, ILGF-1 which stimulate tumor growth
  • adipose tiss hypoxia due to inc growth and press leads to angiogenesis
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185
Q

Cytokine cause of CA

A
  • damages DNA
  • promotes gene mutations
  • enhance angiogenesis
  • promotes proliferation
  • increases ROS
  • cytokines cause endothelial dysfunction
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186
Q

Obesity and CA prevalence

A
  • 2nd most common preventable cause of cancer
  • soon may become #1
  • causes 5-10% of CA
  • increasing cause of cancer in young adults
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187
Q

Causes reactive oxygen species

A
  • obesity, adiposopathy, smoking, and dec expenditure
  • makes imbalance that body can’t clear
  • damage DNA and contribute to CA
  • contributes to aging
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188
Q

foods helpful anti-oxidants

A
  • apples, cherries, grapes, grapefruit
  • tomatoes, squash
  • berries
  • crufiferous and green leafy veggies
  • legumes
  • nuts
  • high fiber whole grains
  • some coffees and teas
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189
Q

Candidates for bariatric surgery

A
  • BMI >/= 40
  • BMI >-= 35 with co-morbidities
  • potential in future for BMI >30 with complications
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190
Q

Bariatric pre-op evaluation

A
  • medical evaluation
  • mental health
  • nutritional assessment
  • educational support
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191
Q

Roux-en-Y stats

A
  • best improvement in metabolic dz over sleeve
  • inc risk of malabsorptive complications
  • wt loss 60-75%
  • better for higher BMI, GERD, DM2
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192
Q

Sleeve stats

A
  • improves metabolic dz
  • nutrient deficiencies are uncommon
  • no long term data
  • wt loss 50-70%
  • good for those with metabolic dz
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193
Q

lap band stats

A
  • least invasive
  • 25-40% need removed
  • wt loss 30-50%
  • better for lower BMI without metabolic synd
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194
Q

Biliopancreatic diversion with duodenal switch stats

A
  • greatest amt wt loss and resolution of disease
  • inc risk deficiencies
  • wt loss 70-80%
  • best for higher BMI, DM2
  • most technically challenging
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195
Q

Other FDA approved bariatric techniques

A
  • Aspiration therapy with modified PEG
  • Vagal n blocking
  • intragastric balloons
  • endoscopic plication devies
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196
Q

Aspiration therapy with modified PEG

A
  • removes 30% of ingested meal
  • use if BMI 35-55
  • lose 12% in 1 yr
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197
Q

Vagal n blocking

A
  • decreases hunger and inc satiety
  • use if BMI >40 or >35 with co-morbidities
  • cause 8.5% wt loss
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198
Q

intragastric balloons

A
  • inserted into stomach and filled
  • Use if BMI >30 and <40
  • approved for 6 mth use
  • cause 12-31% wt loss
  • can cause blockage, N/V, ulcer, gastric hypertrophy
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199
Q

Endoscopic plication devices

A
  • sutures the stomach smaller without removal, done endoscopically
  • cause 30-50% wt loss
  • currently in investigation phases
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200
Q

Early complications bariatric surgery

A
  • leak or perforation
  • Bleeding
  • Wound infection
  • Gastro-gastric fistula
  • Band erosion
  • incisional hernia
  • internal hernia
  • intestinal obstructin
  • stricture
  • band obstruction
  • dumping syndrome
  • GB dz
  • marginal ulcer
  • micronutrient deficiences
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201
Q

Leak and perforation

A
  • more after complicated procedures
  • cause acute peritonitis
  • NL in 72 hrs to 14 days
  • F/C, tachy, abd pain, WBC
  • need urgent surgical management
  • use water soluble contrast if able
  • imaging not always diagnostic
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202
Q

Bleeding after bariatric surgery

A
  • at surgery site or GI bleed
  • NL in 72 hrs
  • may need reoperation
  • tachy, hypotension, dec H&H, oliguria
  • after 3 days is more likely due to erosions or ulcerations at anastomoses and stable lines
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203
Q

Gastro-gastric fistula

A
  • Causes inc capacity to ingest food an/or inc passing of food into gastric remnant
  • may cause suboptimal wt loss and recurrent of metabolic dz
  • non-healing ulcer should raise concer
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204
Q

Band erosion

A
  • suspect if band full, but pt doesn’t feel restriction
  • can present with infection and pain
  • diagnose with EGD, need removal of band
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205
Q

Incisional hernia

A
  • more with open procedures
  • may need CT/us to confirm
  • repair normally post-poned until after wt loss
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206
Q

internal hernia

A
  • intermittent, post-prandial pain and emesis
  • due to herniation th/ defect in mesentery
  • need surgical correction
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207
Q

Intestinal obstruction

A
  • usually 6 mths or longer from surgery

- due to internal hernia, scarring, narrowing of limb, intussusception, or adhesions

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208
Q

stricture

A
  • post-prandial epigastric abd pain and V
  • usually 4-6 wks following RNY
  • may be due to narrowing of anastomoses regions
  • tx with EGD +/- balloon dilation
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209
Q

Dumping syndrome

A
  • more in RNY
  • common in first 18 mths
  • occurs in 70-85%
  • facial flushing, lightheaded, fatigue, hypoglycemia, post-prandial diarrhea
  • avoid high glycemic foods, avoid fluids with meals
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210
Q

Marginal ulcer

A
  • occurs at anastomosis site, most in RNY
  • PPI tid and carafate
  • opitmize protein
  • surgery if not heal
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211
Q

RNY micronutrient defiencies

A
  • B1
  • B9
  • B12
  • D
  • Ca
  • Fe
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212
Q

Sleeve micronutrient deficiences

A
  • B1
  • B9
  • B12
  • D
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213
Q

LAGB micronutrient deficiences

A
  • B1

- B12

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214
Q

BPD micronutrient deficienes

A
  • A
  • B1
  • B9
  • B12
  • D
  • E
  • K
  • Ca
  • Fe
  • Zn
  • Cu
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215
Q

How to eat after bariatric surgery

A
  • start with 3-5 small meals per day
  • limit liquids until 30 min after meal
  • chew thoroughly
  • protein 60g/d (1.2-1.5g/kg/d)
  • avoid concentrated sweets
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216
Q

Vitamin supplementation post-op

A
  • bariatric MTV
  • B12 500 mcg/d or 1000 mcg/m IM
  • iron 27 mg daily with 500 mg vit C
  • Ca citrate 1200 mg/d with Vit D3
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217
Q

Vit A replacement

A

If corneal keratinization and ulceration- 50-100,000 IU IM x3d, then daily for 2 weeks
If no corneal changes- 10,000-25,000 IU po for 1-2 wks

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218
Q

Vit A supplement

A

If on-going losses

- 5000 IU/day

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219
Q

Vit B1 replacement

A

If hyperemesis:

- 100 mg IV x7d, then 50 mg/d until normal

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220
Q

Vit B1 (thiamine) maintenance supplement

A

3 mg per day

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221
Q

Vit B9 (folate) replacement

A
  • cont supplement with 400 mcg

- add 800 mcg/d po until in normal range

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222
Q

Vit B9 (folate) supplement

A

If issues with deficiency should have at least 500 mcg/d

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223
Q

Vit B12 (cobalamin) replacement

A

Until in normal range:

  • 1000 mcg/month IM
  • 1000 mcg/wk sublingual
  • 350-500 mcg/d oral
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224
Q

Vit B12 supplement

A

500-1000 mcg po daily or do monthly injection 1000 mcg

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225
Q

Calcium replacement

A
  • ensure adequate vit D
  • Calcium citrate 1200-1500 mg/d
  • citrate better absorbed than carbonate
  • take 1 hr apart from other supplements, especially iron
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226
Q

Vitamin D replacement

A

50,000 U weekly until in normal range

- then D3 3,000 U if still substantial malabsorption

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227
Q

Vit D supplement

A

Once normal, maintain on:

  • D3 1,000 U after gastric bypass
  • D3 2,000 U after BPD/DS
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228
Q

Vit D3

A

cholecalciferol

- prefered over D2 due to longer 1/2 life and more potent

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229
Q

Vit D2

A

ergocalciferol

- dietary vit D found in plants

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230
Q

Vit E replacement

A

400-800 IU/d po

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231
Q

Zinc replacement

A

60 mg elemental Zn bid

- Zn inhibits copper absorption, so need 1 mg Cu for every 10 mg Zn given

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232
Q

Zinc supplement

A
  • if continued malabsorption, then 30 mg/d

- if less risk, then 8-15 mg/d

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233
Q

microbiom

A

collection of micro-organisms

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234
Q

microbiotia

A

organisms themselves

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235
Q

function gut microflora

A
  • metabolize essential nutrients
  • synthesize vit K
  • fermenting sugars
  • digest cellulose
  • promote angiogenesis
  • enhancing enteric n function
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236
Q

bariatric surgery changes to microbiome

A
  • dec availability of nutrients to gut
  • dec lipogenic signaling
  • dec inflammation
  • dec extraction of calories from carbs
  • alter gut hormones
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237
Q

Obesity prevalence

A

2015-2016 40% of adults and 18.5% youth

  • AA and hispanic more affected
  • Asians least
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238
Q

Melanocortin 4 receptor deficiecy

A
  • obesity
  • hyperphagia starting in early childhood
  • insulin resistance
  • inc bone mineral density
  • accelerated linear growth
  • dec sympathetic nervous system activity
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239
Q

Melanocortin 4 rec def genetic abnormality

A
  • AD or AR
  • most common genetic defect causing obesity
  • polymorphism of gene on chrom 18q22
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240
Q

prader-willi syndrome

A
  • obesity
  • hyperphagia
  • short stature
  • poor growth
  • weak m tone
  • small hand/feet
  • developmental delay
  • underdeveloped genitals
  • mild/mod MR
  • narrow forehead
  • triangle mouth
  • almond eyes
  • fair skin, light hair
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241
Q

prader-will genetic abnormality

A
  • not inherited
  • loss of function mutation chrom 15
  • most common human obesity syndrome
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242
Q

Albright’s hereditary osteodystrophy

A
  • obesity
  • short stature
  • round face
  • skeletal defects (shortened metacarpals and metatarsals)
  • dental hypoplasia
  • soft tissue calcifications
  • pseudohypoparathroidism
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243
Q

Albright’s hereditary osteodystrophy genetic abnormality

A
  • assoc with defect gene GNAS1
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244
Q

Bardet-Biedl Syndrome

A
  • obesity
  • HTN, DM, HLD
  • blindness (retinal dystrophy and pigmentary retinopathy)
  • anosmia
  • hearing loss
  • dysmorphic extremities
  • poor coordination
  • dental abn
  • intellectual disability
  • beh/emotional issues
  • hypogonadism
  • renal cystic dz, renal insufficiency
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245
Q

Bardet-Biedl syndrome genetic abnormality

A
  • AR
  • mutation in at least 16 genes involved in cilia
  • leads to abn cell movement, chemical signaling, and sensory input
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246
Q

cohen syndrome

A
  • obesity
  • DD
  • MR
  • small head
  • narrow hands and feet
  • weak tone
  • retinal dystrophy
  • joint hypermobility
  • thick hair, eyebrows, and lashes
  • open mouth expression
  • leukopenia
  • overly friendly
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247
Q

cohen syndrome genetic abnormality

A
  • AR

- mutation VPS13B

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248
Q

Borjeson-Forssman-Lehman Syndrome

A
  • mostly males
  • MR
  • Seizures
  • large earlobes
  • short toes
  • small genitalia
  • gynecomastia
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249
Q

Borjeson-Forssman-Lehman syndrome genetic abnormality

A
  • X-linked

- mutation Zn finger gene PHF6

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250
Q

lipodystrophy

A
  • congenital or acquired limitation in the proliferation and differentiation of fat cells
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251
Q

Lipodystrophy characteristics

A
  • hyperphagia
  • muscular appearance due to lack of fat
  • leptin levels dec
  • insulin resistance
  • Hypertriglyceridemia
  • hepatic steatosis
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252
Q

Familial partial lipodystrophy (FPLD)

A
  • 3 types
  • leptin levels dec
  • DM
  • hypertriglyceridemia
  • tx- nutrition, exercise, metreleptin, bypass
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253
Q

FPLD type 1

A
  • mostly women
  • lipodystrophy arms, legs, breasts
  • inc central obesity
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254
Q

FPLD type 2

A
  • lipodystrophy arms, legs, buttocks, abd, and chest
  • inc fat back, face, and chin
  • cushingoid appearance
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255
Q

FPLD type 3

A

similar to type 2

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256
Q

Metreleptin

A
  • SC injection
  • leptin analog
  • used to tx leptin deficiency and generalized lipodystrophy
  • men 2.5 mg daily (inc by 1.25-2.5/day with max of 10)
  • women 5 mg daily (inc by 1.25-2.5/day with max 10)
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257
Q

metreleptin drug interactions

A
  • affects CYP p450

- renally cleared

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258
Q

SE metreleptin

A
  • HA
  • hypoglycemia
  • dec wt
  • abd pain
  • warning if T cell lymphoma, autoimmune dz, and hypersensitivity
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259
Q

Diagnostic questionnaires for OSA

A
  • Berlin sleep questionnaire
  • epworth sleepiness scale
  • STOP-BANG
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260
Q

STOP-BANG

A

Snoring
Tiredness
Observed apnea
high blood Pressure

BMI >35
Age >50
Neck >40 cm
Gender male
1 pt for each and 3 pts is high risk
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261
Q

Sleep lab diagnosis of OSA

A

Done by AHI (apnea hypopnea index)

  • mild 5-15/hr
  • mod 15-30
  • sev >30
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262
Q

Consequences of untreated OSA

A
  • worsening obesity
  • CHF
  • Afib
  • Nocturnal dysrhythmias
  • CVA
  • HTN
  • DM2
  • Pulm HTN
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263
Q

Peripheral SQ adipose tissue (SAT)

A
  • does have some protective effects, however, when too much is pathogenic
  • leads to overflow into other organs and inc risk metabolic dz
  • 80% of total fat mass
  • most of adipose derived FFA come from SAT
  • inc in abd SAT inc risk for metabolic dz and CVD, though VAT is higher
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264
Q

Visceral adipose tissue (VAT)

A
  • high lipolysis than SAT
  • dec sensitivity to insulin
  • more associated with metabolic dz and CVD than SAT
  • surrogate marker for global fat dysfunction
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265
Q

benign multiple symmetrical lipomatosis

A
  • inc fat in SQ areas of arms, legs, shoulders, and neck
  • inc sec anti-inflammatory adipokines
  • not normally develop endocrine or lipid disorders
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266
Q

Metabolically healthy but obese (MHO) phenotype

A
  • prevalence varies widely based on criteria
  • higher rates of heart dz and CHF
  • still experience fat mass dz
  • 30-40% will dev metabolic dz within 6 yrs
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267
Q

Metabolically obese normal weight (MONW) phenotype

A
  • may have genetic or acquired dysfunction of other body organs leading to abn metabolic function of adipose tissue
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268
Q

Why asians have inc metabolic dz and lower BMI

A
  • larger adipocyte size
  • dec adipocyte number
  • inc android fat distribution and visceral fat distribution
  • inc FFA and leptin
  • inc pro-inflam factors
  • inc insulin resistance
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269
Q

Stress and obesity

A
  • prolonged stress response increased blood cortisol and glucose
  • promotes unhealthy eating behaviors
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270
Q

gourmand syndrome

A

occurs with damage to R frontal lobe (trauma or CVA)

- post-injury passion for gourmet foods

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271
Q

2 compartment body areas

A
  • fat mass
  • fat free mass
  • can be evaluated by DXA, underwater weighing, air displacement plethysmography, bioelectrical impedence, skin fold thickness, deuterium dilution
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272
Q

3 compartment body areas

A
  • fat mass
  • total body water (lean tissue mass)
  • fat free dry mass (bone and protein)
  • DXA can assess all 3
  • bioelectrical impedence may also
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273
Q

4 compartment body areas

A
  • fat mass
  • total body water
  • bone mineral
  • protein
  • can be assessed by combining 2 different methods (ie DXA + bioimpedence)
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274
Q

6 compartment body areas

A
  • fat mass
  • total body water
  • bone mineral
  • non-bone mineral
  • protein
  • glycogen
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275
Q

Gold std for body composition

A
  • DXA

- most dependable for measuring body fat, lean mass, and bone density

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276
Q

android region on DXA

A
  • area between ribs and pelvis
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277
Q

trunk region on DXA

A
  • area between hip joints and lower chin
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278
Q

Body composition

A
  • about 60% is water
  • 75% of m and organs is water
  • 30% of bone is water
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279
Q

DXA assessment of m mass

A
  • doesn’t always include clear normals
  • vary among individuals, gender, age, and PA
  • %fat lower in AA
  • % fat higher in hispanic
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280
Q

Whole body plethysmography

A
  • measures volume by displacement
  • no exercise 2 hrs prior
  • no eating or drinking 1 hr prior
  • light, tight fitting clothing
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281
Q

bioelectrical impedance analysis

A
  • accurate
  • most inexpensive
  • hydration dependent
  • electric current flows more easily through water and m than fat
  • remove all metal prior
  • use restroom prior
  • no exercise for 8 hrs
  • avoid caffeine or alcohol 12 hrs prior
  • may over or under estimate % fat compared with DXA
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282
Q

deuterium dilution

A
  • isotope of hydrogen
  • mixes with water in the body and eliminated in urine, saliva, and sweat
  • collect pre and post 3-4 hrs saliva specimen and calculate TBW based on total dose/(saliva pre-baseline post)
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283
Q

energy expenditure

A

amt of energy needed to carry out function

  • resting metabolic rate (5-10%)
  • PA (1-2%)
  • dietary thermogenesis (20%)
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284
Q

energy expenditure in mod PA individuals

A
  • 70% resting metabolic rate
  • 20% PA
  • 10% dietary thermogenesis
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285
Q

NEAT

A
  • non-exercise activity thermogenesis
  • ie: standing, maintaining posture, stairs, walking, etc
  • often represents the widest variance in total energy expenditure
  • improving this can be better than just increased bouts of exercise
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286
Q

average steps for Americans

A

<5000/d

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287
Q

activity level based on steps

A

<5000 sedentary
5000-7500 low active
7500-10,000 mod active
>10,000 active

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288
Q

Calories burned per steps

A

approximately 1 cal/20 steps

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289
Q

basal metabolic rate

A
  • energy expended while fasting, rested, and supine

- increased with greater body weight

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290
Q

resting metabolic rate

A
  • energy expended at rest

- increased with greater weight

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291
Q

Resting metabolic rate use

A

In NL weight:

  • skeletal m <25%
  • liver 20%
  • brain 20%
  • RMR 40%
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292
Q

direct calorimetry

A
  • measures heat generated by organism

- value of generated heat can estimate energy expenditure

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293
Q

indirect calorimetry

A
  • estimates basal energy expenditure and resting energy expenditure by O2 consumption and CO2 production
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294
Q

direct calorimetry formula

A

TEE = 60% from heat + 40% from ATP production

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295
Q

Weir equation

A

Indirect calorimetry

- EE = VO2 + VCO2- Nitrogen

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296
Q

Respiratory quotient

A

Indirect calorimetry

- RQ = CO2 production/O2 consumption

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297
Q

estimation of resting metabolic rate

A
  • can be calculated based on pt characteristics

- harris-benedict and mifflin St. Jeor equation

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298
Q

metformin benefits

A
  • improves insulin resistance, PCOS, fatty liver, CAD
  • may help reduce CA rate of colon, ovarian, lung, breast, and prostate
  • may dec appetite through inc GLP-1 and dec peptide YY
  • improve insulin sensitivity
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299
Q

general principles of healthy diet

A

Avoid:

  • highly processed foods
  • sweets, junk foods
  • energy dense beverages

Encourage:

  • healthy proteins and fats
  • veggies, fruits, berries
  • nut, legumes, whole grains
  • complex carbs over simple
  • low GI over high GI
  • high fiber over low fiber
  • read labels
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300
Q

Saturated fats

A
  • carbon chain fatty acids with no double bonds
  • solid or semisolid at room temp
  • less likely to become oxidized and rancid
  • coconut and palm oils have large amounts of
  • Found in meats, dairy, vegetable oils
  • can impair endothelial function
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301
Q

Polyunsaturated fats

A
  • carbon chain fatty acids with multiple double bonds
  • liquid at room temp
  • ie: vegetable and fish oils
  • include nuts, omega 3s from fish
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302
Q

monounsaturated fats

A
  • carbon chain fatty acids with one double bond
  • liquid at room temp
  • ie: olive and canola oil
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303
Q

resistive strength training

A
  • emphasize “core” m exercises
  • use variety of free weights, machines, and bands
  • sore m can be normal
  • sore joints mean poor technique
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304
Q

METS

A
  • metabolic equivalent tasks
  • equal to amt of energy expended during 1 min while lying down to rest
  • kcal = METS x wt x time
  • standing = 2
  • walking 4 mph = 4
  • running 10 mph = 16
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305
Q

types of resistance

A
  • arguing
  • denying
  • ignoring
  • interrupting
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306
Q

ways to roll with resistance

A
  • simple reflection (restate what the patient has said about themself)
  • shift focus back to most important issues
  • reframe the concerns the patient has
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307
Q

identify discrepancy

A
  • find mismatch between patients today and how they want to be in the future
  • find contrasts between current behavior and life goals
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308
Q

amplify discrepancy

A
  • can help resolve ambivalence

- can facilitate thoughts of change

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309
Q

resolve ambivalence

A
  • discuss benefits for change, risks of change, and benefit/risk of no change
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310
Q

illicit talk of change

A
  • how important is it
  • what will happen if they don’t change
  • how do actions fit values
  • how do they plan to change
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311
Q

Change metrics

A
  • scale 1-10 rate how important the change is (facilitates talks of benefits)
  • scale 1-10 rate readiness to change (facilitates talks of stage of readiness)
  • scale 1-10 rate confidence in ability to change (facilitates talks of barriers)
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312
Q

self-efficacy affirmations and feedback

A
  • focus on past successes

- highlight existing strengths

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313
Q

OARS of motivational interviewing

A
  • open ended questions
  • affirmation
  • reflections
  • summaries/plan
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314
Q

FRAMES of motivational interviewing

A
  • Feedback and personal risk
  • responsibility of pt
  • advice to change
  • menu of strategies
  • empathetic style
  • self-efficacy
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315
Q

Behavioral therapy

A
  • helps people to reflect on their current behaviors and make strategies to change those behaviors to more positive ones
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316
Q

Areas of behavioral therapy

A
  • physiologic
  • mental stress
  • timing and emotions
  • environment
  • information gap
  • reward
  • eating disorders
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317
Q

physiologic behavioral area

A
  • biologic forces causing weight gain or preventing loss
  • hypothalamic dysfunction
  • 5 senses giving signals to eat
  • more hunger or lack of satiety
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318
Q

lisdexamfetamine dimesylate

A

used to tx binge eating disorder

  • CNS stimulant
  • not indicated for wt loss
  • schedule II drug
  • dose in AM to avoid insomnia
  • start 30 mg qAM x1 wk, then 50 mg x1 wk, then 70 mg max dose
  • renally dose
  • interaction with MAOIs causing hypertensive urgency
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319
Q

lisdexafetamine SEs

A
  • anorexia
  • anxiety
  • dec appetite and wt
  • diarrhea
  • dry mouth
  • irritability
  • insomnia
  • nausea
  • upper abd pain
  • vomiting
  • tachycardia
  • constipation
  • jittery
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320
Q

lisdexafetamine contraindications

A
  • other CNS stimulants
  • h/o drug abuse
  • allergic rxn
  • MAOIs (don’t use within 14 days of last dose)
  • avoid if known CAD, CVA, CHF
  • uncontrolled HTN
  • Raynauds, PVD
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321
Q

wt loss and neurohormonal changes

A

Promotes wt gain:

  • dec leptin, insulin, cholecystokinin, peptide YY which all inc appetite
  • inc ghrelin which inc appetite
  • continuous high levels of insulin and leptin lead to resistance which limits appetite reduction when people are obese
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322
Q

why people regain weight

A
  • neuro-biologic processes to resist under-nutrition
  • weak resistance of body to overnutrition
  • neurohoromonal changes that stimulate appetite
  • resistance to insulin and leptin
  • lack of routine maintenance for diet and exercise after
  • decreased resting energy expenditure
  • greater m efficiency so less energy expended in PA
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323
Q

Stimulus control

A
  • avoid eating for times except with hunger
  • avoid frequent snacking
  • avoid binge eating
  • portion control
  • remove unwanted foods from environment
  • be mindful of eating stimuli
324
Q

cognitive restructuring

A
  • address body image issues
  • reshape negative thoughts which lead to dysfunctional eating
  • emphasize realistic weight loss expectations
325
Q

Support for weight loss

A
  • stress management
  • back-up activities to engage in during stressful times
  • health care team
  • mental health
  • social
  • commercial programs
  • support groups
326
Q

Technology for weight loss

A
  • apps can help record and assess nutrition and PA
  • web-sites can give helpful food and PA information, recipes, support, etc
  • social media for support and tips
327
Q

pharmacotherapy metabolism and obesity

A 
Oral administration leads to:
Metabolism by GI tract and liver by first pass effect
- GI enzyme breakdown
- bacterial enzyme breakdown
- phase 1 reactions
- phase 2 reactions
328
Q

phase 1 metabolism of medication

A
  • most by CYP450 system
  • oxidizes the compound
  • makes active to inactive drugs or prodrugs into active metabolites
  • products excreted or undergo further conjugation
329
Q

phase 2 metabolism of medication

A
  • conjugation by glucuronidation, acetylnation, methylation, etc
  • most however are inactive and are excreted
330
Q

Cell transporters for medications

A
  • many compounds utilize transporters to get across cell membranes or e used for their actions
  • will bind to proteins to promote longevity and availability
331
Q

hydrophilic drugs

A
  • polar
  • mainly in circulation, not much in tissue
  • transported into tissue by transporters
  • eliminated by kidneys
  • dose may be based on IBW
332
Q

lipophilic drugs

A
  • non-polar
  • mainly in body tissue
  • can cross membranes
  • dose based on actual BW
  • stay in tissue longer
333
Q

GFR in obesity

A
  • often have increased GFR

- some estimates are not validated in pts with obesity

334
Q

Phentermine dosing

A
  • phentermine HCl 4-8 mg tid qAC
  • phentermine resin 15-30 qAM
  • phentermine HCl 18.5-37.5 qAM
  • renal excretion, so caution in renal impairment
335
Q

phentermine drug interactions

A
  • MOAIs, none within 14 days
  • alcohol
  • may need to reduce insulin or OHMs
  • adrenergic neuron blocking drugs
336
Q

phentermine equivalent dosing

A

phentermine HCL 8-37.5 is equivalent to phentermine resin 6.4-30 mg

337
Q

orlistat contraindications

A
  • chronic malabsorption syndrome

- cholestasis

338
Q

contrave drug interactions

A
  • MAOIs
  • opiates
  • SSRIs/TCAs caution
  • anti-psychotics
  • beta-blockers
  • digoxin
  • plavix can inc wellbutrin concentration
  • carbamazepine, phenobarb, and phenytoin dec wellbutrin
  • dopaminergic drugs
339
Q

qysmia and OCPs

A
  • may alter exposure to OCPs causing irregular bleeding, but not an increased risk of pregnancy
  • don’t d/c OCPs during use
  • women should have neg preg test prior and monthly
340
Q

monitoring on qysmia

A
  • pregnancy tests
  • HR
  • depression/SI
  • metabolic acidosis
  • elevated Cr
  • possible hypoglycemia
341
Q

dietary fiber for wt loss

A

Reports of wt loss are inconsistent

  • inc fullness
  • delay carb absorption
  • dec fatty liver
  • inc insulin sensitivity
  • SEs bloating, flatus
342
Q

prebiotics for wt loss

A

some human studies with weight loss, but most rodent models

  • indigestible oligosaccharides
  • stimulate intestinal growth to make better microbiome for wt loss
  • SEs bloating, flatus
343
Q

probiotics for wt loss

A

some human studies with wt loss, most in rodents

  • SEs bloating and flatus
  • help protect against yeast and other bacteria overgrowth
344
Q

caffeine for wt loss

A

Some minor wt loss

  • dec appetite
  • inc fat oxidation
345
Q

green tea for wt loss

A

Minor wt reduction by meta-analysis

  • contains caffeine and epicatechin
  • antioxidant
  • SEs: caffeine SEs, constipation, indigestion, liver injury
346
Q

green coffee for wt loss

A

Minor wt loss

  • less caffeine than black coffee
  • contains chlorogenic acid
347
Q

Phytoestrogens for obesity

A

Minor wt loss if used as substitute for higher fat or higher calorie foods

  • found in soy products
  • SEs N, bloating, constipation, hormone abn
348
Q

Conjucated linoleic acid (CLA) for obesity

A

possible short-term minor wt loss

  • natural trans-fat
  • promotes lipolysis, thermogenesis, and browning of fat
  • SEs: N, indigestion, diarrhea, fatigue, fatty liver, insulin resistance, inc cholesterol, inc inflammation
349
Q

Supplements with insufficient data for wt loss

A
  • chitosan
  • berberine
  • forskolin
  • garcinia cambogia
  • glucomannan
  • glucosinolates
  • hoodia gordonil
  • irvingia gabonensis
  • raspberry ketones
  • geranium
  • ephedra
  • bitter orange
  • DNP
  • PPA
  • sibutramine
350
Q

Unsuccessful wt loss supplements

A
  • hCG
351
Q

Cardiovascular changes in obesity

A
  • inc HR if inactive
  • in risk Afib
  • inc blood volume
  • inc CO
  • inc vascular resistance
  • inc arterial pressure
  • inc pulm a pressure
352
Q

Heart structure changes in obesity

A
  • myocardial fibrosis and apoptosis
  • fat deposition in heart (epicardial and myocardial)
  • inc coronary calcium
  • LAE
  • LV and RV hypertrophy
353
Q

Endocrinopathy related to obesity

A
  • activate sympathetic nervous system
  • activation RAAS
  • hyperinsulinemia
  • hyperleptinemia leading to leptin insensitivity
354
Q

heart function change with obesity

A
  • hypoxia
  • LV diastolic and systolic dysfunction
  • R heart failure
355
Q

immunopathies with obesity

A
  • inc pro-inflammatory cytokines
  • inc inflammatory macrophaes, T-cells, mast cells
  • dec anti-oxidants
  • inc CRP
356
Q

“Sick” epicardial adipose tissue (EAT) fat

A
  • supplies pro-inflammatory cells and cytokines to vasa vasorum
  • contribute to dysfunction, fibrosis, and electrical remodeling
  • excessive FFA oxidation making toxic metabolites
  • impairs mitochondrial function
  • leads to myocardial inflammation and dysfunction
  • vasoconstriction
  • arterial stiffness
  • worsening of plaques
  • weakening of the arterial walls
  • predispose to plaque rupture
357
Q

action of insulin

A
  • binds to cell and activates MAP and P13K signaling
  • inc cell growth
  • cause glycogen, lipid, and protein synthesis
  • increased NO production and vasodilation
358
Q

macrophages in obesity

A
  • recruited to areas of fat due to adipocyte cell death, hypoxia, inc signaling
  • M1 macrophages inc in obesity and secrete TNF, IL-6, and MCP-1 pro-proinflammatory
  • M2 macrophages are predominant in lean and secrete anti-inflammatory factors
359
Q

Adiponectin in obesity

A

decreased

  • it is an anti-inflammatory cytokine that helps with insulin sensitization and glucose uptake
  • leads to inc intra-abdominal fat
  • inc apoB
  • inc TG, dec HDL, inc LDL
360
Q

Normal eating and BP

A
  • eating stimulates parasympathetic nerv sys and catabolic sympathetic nerv sys
  • get inc blood flow to splanchnic vessels and inc vasodilation
  • can lead to dec BP and hypotension
  • get inc HR
361
Q

Lipids in adipocytes

A
  • cholesterol is a small fraction of lipids in adipocytes
  • majority are TG
  • HDL scavengers bring cholesterol to the fat cells
362
Q

TNF

A
  • pro-inflammatory cytokine
  • impair FFA uptake by adipose tissue
  • impairs adipogenesis
  • promotes lipolysis
  • dec insulin sensitivity
  • increased in obesity
363
Q

IL-6

A

Inc in obesity

  • pro-inflammatory
  • promote adipocyte lipolysis
  • inc TG synthesis
  • dec apo A1
  • dec HDL, inc LDL
364
Q

lipoprotein lipase

A
  • found on surface of capillaries
  • inc in obesity
  • get inadequate hydrolysis of TG, so inc TG levels
365
Q

cholesteryl ester transfer protein (CETP)

A
  • facilitates exchange of TG and cholesteryl esters
  • inc in obesity
  • get dec HDL and small dense LDL
366
Q

Testosterone and cholesterol

A
  • inc LDL
  • dec TG
  • dec HDL
367
Q

Estrogen and cholesterol

A
  • dec LDL
  • inc TG
  • inc HDL
368
Q

Affect of excess FFA

A
  • Inc deposition in liver–> steatosis
  • inc liver secretion of VLDL–> hypertriglyceridemia
  • inc LDL and VLDL remnants
  • inc renal clearance of HDL–> low HDL
369
Q

Fat deposition and liver disease

A
  • get accumulation of FA, cholesterol, and toxic lipids
  • makes ROS that lead to mitochondrial dysfunction and hepatocyte death
  • promotes more pro-inflammatory response
  • get hepatitis then continued inflammation leads to scarring and fibrosis
370
Q

fatty liver dx

A
  • inc ALT >AST
  • can have normal LFTs though
  • u/s can miss NAFLD with liver fat <20%
  • fibroscan can detect mild changes
  • CT
  • MRI- specialized to look at fat is most accurate
371
Q

hepatic fibrosis tools

A
  • NAFLD fibrosis score
  • fibrosis 4 calculator
  • serum biomarkers
372
Q

hepatic fibrosis imaging

A
  • transient elastography
  • MRE
  • shear wave elastography
373
Q

hepatic fibrosis dx gold standard

A
  • biopsy
374
Q

Obesity and cancer formation

A
  • cytokines damage DNA
  • promote cell mutations
  • promote angiogenesis and cell proliferation
  • mitochondrial stress
  • release of ROS
  • promote endothelial dysfunction
  • insulin gives growth factors to cancer cells
  • promotes cancer promoting hormones
375
Q

food intake and cancer production

A
  • high intake processed meats (bacon, sausage, lunch meat, hot dogs)
  • more smoke from grilling
376
Q

foods components beneficial in cancer

A
  • phytochemicals
  • fiber
  • antioxidants
377
Q

foods good for cancer

A
  • apples
  • cherries
  • citrus fruits
  • berries
  • green leafy veggies
  • carrots
  • garlic
  • legumes
  • nuts
  • whole grains
  • coffee and tea
378
Q

anti-obesity drugs in development

A
  • GLP1 agonists (mono and combined with GIP and PYY)
  • oxyntomodulin agents
  • Peptide YY agents
  • neuropeptide Y antagonist
  • melanocortin-4 rec agonist
  • ghrelin O-acyltansferase inhibitor
  • triple monoamine uptake inhibitor
  • macrophage inhibitory cytokine 1 agonist
  • leptin analogues
  • zonisamide-buproprion
  • SGLT2 inhibitors
  • amylin mimetics
  • amylin/calcitonin rec agonists
  • lipase inhitoris
379
Q

GLP-1 pathwasy

A

Food goes into system and causes:

  • inc release GLP-1 and GIP
  • GLP-1 inactivated to DPP-4 (GLP-1 agonists help to resist degradation)
  • acts on brain to dec appetite and inc satiety
  • acts on pancreas to dec glucagon and inc insulin
  • acts on stomach to dec gastric emptying and inc nausea
  • acts on fat tissue to dec fat mass and improve adipose function
  • insulin and glucagon acts on m to inc glucose uptake
  • glucagon and insulin act on liver to dec glucose production
380
Q

oxyntomodulin agent pathway

A

released by L-cells in the ileum and colon:

  • activates GLP-1 receptors
  • activates glucagon rec
  • gluc raising of glucagon counteracted by gluc lowering of GLP-1 for net dec in glucose levels
  • act on brain to dec appetite and inc satiety
  • act on pancreas to inc insulin
  • act on stomach to dec gastric emptying, dec ghrelin, and inc N/V
  • act on fat to dec fat mass, inc lipolysis and inc adiponectin
  • cause inc uptake glucose in m and dec prod in liver
381
Q

peptide YY pathway

A

Released by L-cells in ileum and colon

  • structurally similar to NPY and PP
  • circulate in 1-36 and 3-36 form
  • inhibti NPY neurons
  • act on brain to dec appetite and inc satiety
  • act on pancrease to inc insulin, dec proliferation of beta cells, and dec apoptosis of beta cells
  • act on stomach to dec gastric emptying and inc N/V
  • act on fat to dec fat mass
  • inc glucose uptake in m and dec gluc production in liver
382
Q

neuropeptide YY (NPYY) pathway

A

Made in response to fasting

  • orexigenic
  • most abundant peptide in CNS
  • act on brain to inc appetite, dec stress/anxiety and pain
  • act on SNS to inc vasoconstriction
  • act on fat to promote fat storage
383
Q

SGLT-2 inhibitor pathway

A
  • dec proximal renal tubule glucose reabsorption
  • dec GI gluc absorption
  • dec body wt and glucose levels
  • doesn’t cause inc in insulin, so go into fasting/starvation ketone state
  • inc FFA to liver to make ketones
  • restrictive carb diet with this may worsen ketoacidosis
384
Q

early tx for obesity

A
  • try to do interventions early to prevent sick fat disease
385
Q

delayed tx for obesity

A
  • tell person to diet and exercise, but not really engage them fully and tx until after sick fat disease occurs
386
Q

GI hormone regulation of caloric balance before eating

A

Before eating, hormones inc hunger:

  • ghrelin
  • neuropeptide YY
387
Q

GI hormone after eating dec hunger and inc satiety

A

After eating, horm dec hunger and promote satiety:

  • somatostatin
  • cholecystokinin
  • motlin
  • insulin
  • glucagon
  • pancreatic polypeptide
  • amylin
  • fibroblast growth factor 19
  • GLP-1
  • oxyntomodulin
  • peptide YY
388
Q

GI horm after eating promote digestion

A

After eating, horm help with digestion and slow gastric emptying:

  • cholecystokinin
  • amylin
  • GLP-1
  • oxyntomodulin
  • PYY
389
Q

GI horm after eating stimulate digestive enzymes

A
  • gastrin
  • cholecystokinin
  • secretin
390
Q

GI horm after eating impairing digestive enzy release

A
  • somatostatin
  • secretin
  • PP
  • GLP-2
  • oxyntomodulin
  • PYY
391
Q

GI horm after eating assist with nutrient management

A
  • somatostatin
  • insulin
  • glucagon
  • fibroblast growth factor 19
392
Q

Absorption in stomach

A
  • water

- alcohol

393
Q

absorption in duodenum

A
  • fatty acids
  • AA
  • minerals (calcium, iron)
  • some vitamins
394
Q

absorption in jejunum

A
  • simple sugars
  • fatty acids
  • protein
  • minerals
  • vitamin
395
Q

absorption in ileum

A
  • bile salts
  • bile acids
  • vit B12
  • some vitamins and minerals
396
Q

absorption in LI

A
  • water
  • NaCl
  • K
  • intestinally derived vit K
397
Q

Questions when considering bariatric surgery

A
  • BMI and co-morbidities to qualify
  • reasonable attempt to lose weight unsuccessful
  • evaluation by physician and psychologist
  • commitment to following post-surgery recommendations
  • specific insurance requirements
398
Q

surgery requirements

A
  • BMI >40
  • BMI >35 with co-morbidities
  • BMI >30 with co-morbidities may becoming classification
399
Q

bariatric surgery pre-op eval

A
  • medical eval
  • surgical consultation
  • cardio/pulm/GI consult if necessary
  • mental health assessment
  • nutritional assessment
  • educational support
400
Q

roux-en-Y procedure

A
  • stomach divided into small proximal pouch
  • then bypasses rest of stomach, duodenum, and portion small intestine
  • prox stomach added to limb of SI
401
Q

roux-en-Y recovery

A
  • hospital stay 1-4 days

- recovery 1-2 weeks

402
Q

contraindication roux-en-Y

A
  • poor surgical candidate
  • sev psych
  • pregnancy
  • drug or alcohol addiction
  • untreated gastric ulcer
  • crohn’s disease
403
Q

Common acute complications roux-en-Y

A
  • N/V
  • dehydration
  • GI obstruction
  • GI bleed
  • acute gout exacerbation
  • anastomotic leak
  • infection
  • cardiac dyshythmia
  • atelectasis/PNA
  • DVT/PE
  • death
404
Q

Common chronic complications roux-en-Y

A
  • wt regain
  • pouch dilation
  • anastomotic/marginal ulcers
  • dumping syndrome
  • esophageal dilation
  • SBO
  • anastomotic stenosis/stricture
  • gallstones
  • kidney stones
  • 2dary hyperparathyroidisi
  • depression
  • osteoporosis
  • gout
  • bacterial overgrowth
  • metabolic acidosis
405
Q

Common nutritional issues roux-en-Y

A
  • calcium def
  • iron def
  • protein malnutrition
  • def vit A, C, D, E, B, K, folate, Zn, Mg, thiamine
  • neuropathies from def
406
Q

vertical sleeve recovery

A
  • hospital 1-2 days

- recovery 1-2 weeks

407
Q

vertical sleeve contraindications

A
  • poor surgery candidate
  • sev psych
  • pregnancy
  • drug or alcohol addiction
  • untreated gastric ulcer
  • barrett’s
  • achalasia
  • prev gastrectomy
  • prev gastric bypass
408
Q

Common acute complications VSG

A
  • N/V
  • dehydration
  • GI obstruction or bleeding
  • staple line leaks
  • GERD
  • cardiac dysrhythmias
  • atelectasis/PNA
  • DVT/PE
  • death
409
Q

common chronic complications VSG

A
  • wt regain
  • sleeve dilation
  • worsening GERD, de novo GERD
  • stenosis/stricture
  • staple line ulcers and leaks
  • fistula formation
  • gallstones
  • kidney stones
  • depression
410
Q

Common nutritional def VSG

A
  • Ca
  • iron
  • anemia
  • B12 and B1
  • protein malnutrition
  • vitamin def are uncommon
411
Q

BPD with DS recovery

A
  • hospital stay 2-4 days

- recovery 2-4 wks

412
Q

BPD with DS contraindications

A
  • poor surgery candidate
  • sev psych
  • pregnancy
  • addiction
  • untreated gastric ulcer
  • crohn’s dz
  • IBS
413
Q

BPD with DS acute complications

A
  • N/V, dehydration
  • obstruction
  • GIB
  • acute gout
  • anastomotic leak
  • infection
  • dysrhythmia
  • PNA
  • VTE
  • death
414
Q

BPD with DS chronic complications

A
  • wt regain
  • pouch dilation
  • anastomotic ulcers
  • SBO
  • gallstones
  • bacterial overgrowth
  • kidney stones
  • acidosis
  • osteoporosis
  • depression
415
Q

BPD with DS nutritional def

A
  • Ca
  • hyperparathyroidism
  • iron
  • protein
  • vit A, C, D, E, B, K
  • folate, Zn, Mg, thiamine
  • anemia
  • neuropathy
416
Q

aspiration therapy

A

Done by PEG tube

  • drains 30% ingested meal
  • 12% wt loss in 1 yr
417
Q

electrical vagal blocking system

A
  • pacemaker like implant under skin
  • blocks vagal impulses causing dec hunger and inc satiety
  • 8.5% wt loss
  • can cause gastroparesis
418
Q

intragastric balloons

A
  • indicated for BMI >30 and <40
  • approved for up to 6 mths then needs removed
  • fluid filled of gas filled
  • 12-31% wt loss in 6 mths
  • may cause blockage, V, ulcers, gastric hypertrophy, or uncomfortable fullness
419
Q

endoscopic plication

A
  • endoscopic suturing of stomach
  • investigational
  • 30-50% wt loss in 1-2 yrs
420
Q

leak or perforation symptoms

A
  • cause peritonitis
  • most in first 72 hrs post-op
  • can be any time due to ulcer perforation
  • acute, severe abd pain, back pain
  • signs of infection
  • needs urgent surgery
  • use water soluble contrast with imaging, but imaging may be negative
421
Q

bleeding post-op

A
  • most in first 72 hrs
  • tachycardia, hypotension, dec H&H
  • after 1 week more likely due to erosion and ulceration
422
Q

gastro-gastric fistula

A
  • more with RNY
  • have increased ability to eat food
  • may lead to wt gain
  • be concerned for if have non-healing ulcer
423
Q

band erosion

A
  • suspect if band full but pt not feel restriction
  • can present with infection
  • diagnose with EGD
  • need surgery
424
Q

internal hernias

A
  • more with RNY and BPD/DS
  • intermittent, post-prandial pain and emesis
  • get hernia through defect in mesentery
  • surgical emergency if sudden onset
425
Q

stricture

A
  • most 4-6 wks from RNY
  • may be associated with anastomic ulcer
  • occurs at areas of anastomosis
  • repair with EGD +/- balloon dilation
  • surgery if refractory
426
Q

dumbing syndrome

A
  • after RNY
  • due to bypass of pyloric mechanism
  • occurs in 70-85%
  • facial flushing, lightheaded, fatigue, hypoglycemia, and post-prandial diarrhea
  • avoid high glycemic foods and avoid liquids with meals
427
Q

risks for ulcerations

A
  • NSAIDs
  • steroids
  • nicotine
  • alcohol
  • drugs
  • caffeine
428
Q

Common nutritional def post-op RNY

A
  • B1, B9, B12, D, Ca, Fe
429
Q

Common nutritional def post-op Sleeve

A
  • B1, B9, B12, D, Fe
430
Q

Common nutritional def post-op LAGB

A
  • B1, D
431
Q

Common nutritional def post-op BPD

A
  • A, B1, B9, B12, D, E, K, Ca, Fe, Zn, Cu
432
Q

Vit A def

A
  • fat soluble nutrient
  • involved in lipid and glucose metabolism
  • night blindness
  • monitor retinol levels after BPD/DS
433
Q

B1 (thiamine) def

A
  • water soluble nutrient
  • involved in fatty acid oxidation
  • cause beriberi
  • dry beriberi- Wernicke-korsakoff encephalopathy
  • wet beriberi- CHF
  • alcoholics at risk
  • more common in AA and hispanics post-op
  • can be after all surgeries
  • inc risk with post-op vomiting
  • may have weakness, anorexia, constipation, V
434
Q

Wernicke-korsakoff encephalopathy

A
  • dementia
  • ophthalmoplegia
  • ataxia
  • amnesia
435
Q

Vit B2 (riboflavin) def

A
  • water soluble nutrient
  • bright pink tongue
  • cracked lips
  • throat swelling
  • scleral erythema
  • dec blood count
  • coma/death
  • rare complication
  • usually only check if signs of deficiency
436
Q

vit B3 (niacin) def

A
  • water soluble nutrient
  • develop pellagra (diarrhea, dermatitis, dementia)
  • dermatitis mostly in sun-exposed areas
  • rare complication
  • usually only check if signs of deficiency
437
Q

Vit B5 (pantothenic acid ) def

A
  • essential water soluble nutrient
  • used to make coenzyme A, prot, carbs, and fat
  • found in most foods
  • causes wide range of symptoms
  • rarely seen
438
Q

Vit B6 (pyridoxine) def

A
  • essential water soluble nutrient
  • used for neuro function
  • skin eruptions- seborrheic dermatitis, intertrigo
  • atrophic glossitis
  • angular cheilitis
  • conjunctivitis
  • sideroblastic anemia
  • somnolence/confusion/neuropahy
  • rare complication
  • only check if symptoms
439
Q

Vit B7 (biotin) def

A
  • essential water soluble nutrient
  • used in FA and AA synthesis, and gluconeogenesis
  • made by intestinal bacteria
  • hair loss
  • conjunctivitis
  • erythematous rash around eyes, nose, mouth, and genitals
  • anemia
  • CNS/PNS disorders
  • rare
  • check if signs
440
Q

Vit B9 (folate) def

A
  • essential water soluble nutrient
  • megaloblastic (macrocytic) anemia
  • dec appetite, wt loss
  • relatively common in all
  • routinely monitor
  • provide post-op supplementation
441
Q

vit B12 (cyanocobalamin) def

A
  • essential water soluble nutrient
  • absorbed by intrisic factor (IF) in terminal ileum
  • megaloblastic (macrocytic) anemia
  • neuropathy
  • common after all
  • routinely monitored
  • routine supplementation
442
Q

vit c def

A
  • essential water soluble nutrient
  • cause scurvy
  • lethargy, wt loss
  • dry hair and skin
  • bleeding gums, tooth loss
  • F, death
  • rare
  • check if signs
443
Q

vit D def

A
  • essential fat soluble nutrient
  • used in calcium metabolism, bone heath, and fat
  • cause osteopenia, osteoporosis, hypoCa, secondary hyperparathyroidism
  • common
  • lower in AA
  • routine supplementation
  • routine monitoring with 25-OH vit D, Ca, PTH
444
Q

vit E def

A
  • essential fat soluble nutrient
  • used in antioxidant and enzym functions, gene expression, and neuro function
  • cause neuropathy and ataxia
  • rare
  • more often after BPD/DS
  • alpha-tocopherol levels routinely monitored after BPD/DS
445
Q

vit K def

A
  • essential fat soluble nutrient
  • used in coagulation
  • cause easy bruising and bleeding
  • rare
  • more common after BPD/DS
  • PT routinely measured after BPD/DS
446
Q

micronutrients definition

A
  • chemical substances in food which we need only small amount for growth and function
447
Q

phytochemical definition

A
  • bioactive compounds in plants
  • def lead to organ/tissue dysfunction
  • help with oxidative stress
448
Q

minerals definition

A
  • non-organic substances needed to function

- Ca, Ph, Mg, K, Na

449
Q

trace elements definition

A
  • non-organic substances needed for body functions

- Fe, Cobalt, Zn, selenium, iodine, molybdenum

450
Q

Ca def

A
  • essential mineral
  • help with nervous sys, m contraction, bone
  • Mg def may worsen Ca def
  • cause osteoporosis, m tetany/spasm, paresthesia, secondary hyperparathyroidism
  • common after all except band
  • routinely monitor and supplement
451
Q

Copper def

A
  • trace element
  • may accompany iron def
  • get anemia, neuropathy, ataxia, inc m tone/spasm, cardiomegaly
  • rare
  • check if symptoms
452
Q

Iron def

A
  • trace element
  • microcytic anemia, pica
  • common
  • monitor iron, ferritin, transferrin, and total IBC
  • routinely supplement
  • don’t take with calcium
453
Q

selenium def

A
  • trace element
  • protects from free radicals
  • cause keshan dz (cardiomyopathy)
  • rare
  • check if symptoms
454
Q

zinc def

A
  • trace element
  • help with intestine mucosa function
  • cause poor wound healing
  • hair loss
  • acrodermatitis enteropathica rash
  • taste alterations
  • glossitis
  • impaired folate absorption
  • common, more with BPD/DS
  • monitor if signs
455
Q

eating principles after bariatric surgery

A
  • 3-5 small meals
  • dec meals as portions inc
  • chew thoroughly
  • avoid liquids with meals
  • 60g/day prot (1.2-1.5 g/kd/d lean mass)
  • avoid concentrated sweets
  • take MTV
456
Q

supplements after bariatric surgery

A
  • MTV
  • B12 500 mcg/d tab or sublingual or 1000 mcg/mth IM
  • iron 27 mg elemental iron with 500 mg vit C
  • Ca 1200 mg/d with vit D3
457
Q

function of gut flora

A
  • metabolize essential nutrients
  • ferment sugars
  • digest cellulose
  • promote angiogenesis
  • inc enteric n function
458
Q

common gut flora

A

most in ileum and colon

  • G neg bacteroides
  • G pos firmicutes
459
Q

gut flora in obese

A

get increased firmicutes which increased calories absorbed

460
Q

gut flora promotion of inc body fat

A
  • inc nutrient absorption
  • inc lipogenesis
  • inc inflammation
  • alterations in bile acid metabolism
  • alterations gut hormones
461
Q

changes in biotia after surgery

A
  • dec availability of nutrient delivery
  • dec lipogenic signaling
  • dec inflammation
  • alter bile-acid metabolism
  • dec firmicutes
462
Q

% obese/overeright in US

A

70%

- extreme obesity 7%

463
Q

obesity in 3rd world countries

A
  • still see malnutrition

- also having issues with obesity rise

464
Q

reason for increased obesity

A

o Decreased temp variability in surroundings
o Dec length of sleep
o Intestinal bacterial changes
o Medications
o Older maternal age
o Fertility treatments
o Hypothalamic injury from calorie overload leads to resistance to leptin and shift up in “weight setpoint”

465
Q

survival and BMI

A

o BMI 30-35 survival decreased by 2-4 yrs
o BMI 40-45 survival decreased by 8-10 yrs
o Abdominal obesity has higher risk for cardiovascular risk and all-cause mortality

466
Q

predictor of obesity in infants

A
  • BW not as much a factor

- growth rate more influential

467
Q

types of fat

A
  • white
  • brown
  • beige
468
Q

white fat

A
  • release FA
  • TG storage
  • more energy storage
  • chronic cold exposure helps to become beige/brown
469
Q

brown fat

A
  • produces heat
  • burns FA and glucose
  • activating brown fat inc blood flow, cardiac output, and metabolic output
470
Q

beige fat

A
  • can develop into brown fat
471
Q

Different levels of bias

A
  • structural
  • interpersonal
  • intrapersonal
472
Q

types structural bias

A
  • see in advertising

- requirements for wt loss surgery, industry standars

473
Q

types interpersonal bias

A
  • like structural
  • media
  • personal views about others
474
Q

intrapersonal bias

A
  • bias against yourself
475
Q

bias towards obesity

A
  • viewed more negatively than other minority groups
  • even in those treating obesity
  • people who have lost weight on own tend to be more critical and less compassionate.
476
Q

how to talk about obesity

A
  • ask permission
  • open-ended questions
  • focus on behaviors and successes, not just weight
  • focus on health
  • realistic expectations
  • make changes for whole family
477
Q

amount of people who regain weight

A

75-80% in 2 yrs

478
Q

Wt loss and set-pt

A
  • the more weight we gain, the higher our set point and what our body defends
  • when lose wt, need to restrict even more to maintain that wt as opposed to naturally thin people
  • metabolism dec to try to burn less calories
  • doesn’t change even if maintain that wt for years
479
Q

interventions to help maintain wt loss

A
  • resistance training (helps dec m efficiency and burn more calories)
480
Q

crown like structure in fat tissue

A
  • macrophages and T-cells around single adipocyte

- higher amts linked to worse vascular outcomes

481
Q

% wt loss and health outcomes

A
  • 5% wt loss can improve glycemic control

- >10% needed to improve inflammation and metabolic function

482
Q

obesity and addiction to food

A
  • get down regulation of dopamine due to chronic exposure

- may cause inc over-eating to compensate for the dec reward pathway

483
Q

Edmonton obesity staging system (EOSS)

A
  • puts patient in stages 0-4

- based on medical, mental, and functional complications

484
Q

stopping qysmia

A
  • need to taper off higher doses due to topamax
485
Q

realistic wt loss goals

A
  • up to 2 lb/wk

- up to 10% baseline TBW

486
Q

maintaining wt

A
  • after wt loss, still need to restrict calories and inc activity to maintain
  • recommend >250 min/wk mod intensity exercise
  • want to dec calories, but inc quality (low energy dense foods)
487
Q

Calorie reduction for wt loss

A
  • females 1200-1500 kcal/d
  • males 1500-1800 kcal/day
  • dec total intake by 500-750 kcal/d
488
Q

CBT in wt loss

A
  • combining CBT with dietary and lifestyle changes most helpful
489
Q

alternate day fasting

A
  • alternate 25% of calories and 125% calories
490
Q

time restricted eating only in evening

A
  • if restricct eating to evening, actually worse
  • worse glucose, insulin, BP, and lipids
  • still get wt loss though
491
Q

food eating pattern in meal

A
  • eating veggies and prot rich foods first dec glycemic load and lower post-prandial gluc and insulin
492
Q

post-op lab f/u roux-en-Y

A
  • labs every 3-6 months for 1st yr, then annually
  • CBC, CMP, iron studies, B12, lipids, 25-OH vit D
  • consider PTH, thiamine, and folate
493
Q

post-op lab f/u BPD/DS

A
  • every 3 months for 1st yr, then every 3-6 mths

- CBC, CMP, iron studies, B12, lipids, albumin/prealb, folate, A, D, E, K, INR, PTH, Zn, Se,

494
Q

% children with obesity

A
  • 18% have obesity
495
Q

asking about food insecurity

A
  • in past 12 mths did you worry about if food would run out before you got more
  • in past 12 months did the food run out and couldn’t afford to buy more
  • refer + screen to community resources
496
Q

pediatric modifiable factors to prevent obesity

A
  • rate of wt gain in infancy
  • infant feeding (breast, bottle, intro solids)
  • diet quality
  • parent feeding practices
  • routines
  • sleep and PA
  • TV time
  • no sugar
497
Q

good food habits for pediatric obesity prevention

A
  • follow feeding cues
  • food introduction at 6 mths or later
  • breast instead of bottle
  • allow self-feeding
  • no fast food
498
Q

normal infant wt gain

A
  • triple wt by 1 yr

- triple wt again at 9.5 yrs

499
Q

Ellyn Satter Method for peds feeding

A
  • parents decide what, when, and where child eats

- child decides how much to each and if they want to eat

500
Q

3 day eating cycle toddler

A
  • day 1 eat great
  • day 2 graze
  • day 3 not eat much
501
Q

normal BMI pattern in kids

A
  • nadir in BMI around 4-6 yrs b/c more ht than wt gain

- For younger children wt for length chart more helpful

502
Q

high risk BMI pattern in kids

A
  • early nadir around 3-4 yrs
  • then inc wt
  • higher risk obesity in the future
503
Q

very high risk BMI pattern in kids

A
  • never get nadir at 4-6 yrs, just continues to go up

- try to intervene early when don’t see nadir to prevent obesity

504
Q

wt loss goals for kids

A
  • nutrition make 2 goals (1 addition, 1 take away)

- 1 activity goal

505
Q

medicare billing for wt loss visits

A
  • have to record 5As
  • covers up to 22 visits in 12 mths
  • 1 every wk for 1 mth
  • 1 every wk for mth 2-6
  • 1 every mnth for mth 7-12
  • have to show 3 kg wt loss after 6 mths to continue to bill and reassess 5As
  • G0447 with BMI code
506
Q

BEAM box approach to wt loss counseling

A
  • Behavior (stress/emotions)
  • Eating
  • Activity
  • Medical
507
Q

ACEs and obesity

A
  • 2 or more ACEs inc risk of chronic medical problems and metabolic dz
508
Q

stress and obesity

A
  • worse if unpredictable, more intense, prolonged, and repetitive
509
Q

meds and bariatric surgery in adolescents

A
  • if BMI >95% and co-morbidities unsuccessful with others

- if BMI >99% unsuccessful

510
Q

indications for bariatric surgery adolescents

A
  • DM2
  • OSA
  • NAFLD/NASH
  • IIH
  • cardiovascular risks
511
Q

relative indications for bariatric surgery in adolescents

A
  • blount’s dz
  • SCFE
  • GERD
  • dec QoL
512
Q

insurance requirements for adolescent bariatric surgery

A
  • most need 95% growth done prior to surgery
513
Q

surgeries performed in adolescents

A
  • gastric band
  • gastric sleeve
  • sometimes roux-en-Y
  • gastric plication may be in future
514
Q

tx of thyroid for weight

A

doesn’t really help

515
Q

screening labs in obesity

A
  • glucose
  • lipids
  • LFTs
  • TSH
  • A1c
  • +/- CRP
  • vit D
  • consider baseline EKG (for starting meds)
516
Q

BMI indications for meds

A
  • BMI >30

- >27 with co-morbidities

517
Q

additive effects of meds on wt loss

A
  • activity and diet give certain wt loss
  • meds give additional wt loss
  • each med is additive
518
Q

when okay to get pregnant after meds

A
  • 1 mth after stop
519
Q

contrave SEs

A
  • HA common
  • more SEs if faster titration (every week)
  • similar SEs to others
  • need be off opiates 1 week prior to starting and stop med 1 wk prior to any procedure when anticipating opiates
520
Q

insurance and liraglutide

A
  • will cover DM dose max 1.8 mg/d

- won’t cover obesity dose max 3 mg/d

521
Q

other GLP-1s for wt loss

A
  • semaglutide looks promising
522
Q

DM resolution after bariatric surgery

A
  • occurs within days

- likely more related to gut as endocrine organ, not really wt loss

523
Q

peds growth charts for obesity

A
  • have extended growth charts for obesity that show elevated percentiles
524
Q

overweight peds

A
  • 85-94.9%
525
Q

obesity peds

A

> 95th%

526
Q

class 2 obesity peds

A

> 120th% of 95th%

527
Q

class 3 obesity peds

A

> 140th% of 95th%

528
Q

difference in fat distribution peds

A
  • males more visceral

- females more SC

529
Q

risks for peds obesity

A
  • AA, hispanic
  • low SES
  • parental obesity
  • parental DM or other wt co-morbidities
530
Q

which chart to use for peds

A
  • <2 y/o use wt for ht

- >2 y/o use BMI

531
Q

peds screening labs for obesity

A

consider labs in overweight, get in all obese

  • lipids
  • LFTs
  • fasting glucose
  • A1c
  • TSH
  • Vit D
  • UA, urine micro/Cr
  • consider PFTs and sleep study
532
Q

medical risks of obesity in peds

A
  • depression
  • asthma
  • OSA
  • glomerulosclerosis/proteinuria
  • NASH/NAFLD
  • gallstones
  • risk cirrhosis and colon CA
  • forearm fx
  • blount’s dz
  • SCFE
  • DDD risk
  • IIH (pseudotumor cerebri)
  • risk for CVA
  • HLD
  • HTN
  • LVH
  • risk CAD
  • DM2
  • precocious puberty
  • PCOS
  • hypogonadism (boys)
  • hernia
  • DVT/PE
  • stress incontinence
  • risk gyn malignancy
533
Q

ABCD

A

adiposity based chronic disease

  • new wording to try to encompass the idea that obesity is not just a number but is more significant when linked to chronic conditions
  • puts patients into stages
  • still investigational
  • trying to use instead of obesity which is only a number and leaves out a number of factors
  • used to describe the disease state and not just the number
  • “complication-centric” framework of care
534
Q

ABCD factors

A
  • pt must be activated to change
  • key drivers and associated abnormalities need identified
  • need to identify risk, presence, and severity of adipose related chronic conditions
  • careplan needs developed for tx
535
Q

BMI changes over time (prevalence)

A
  • all increasing, but higher BMIs are rising even faster
536
Q

super obesity

A 
- class 4
BMI 50-59.9
537
Q

Super super obeisty

A 
- class 5
BMI >60
538
Q

surgical challenges in super obesity

A
  • more hepatosteatosis
  • magnitude of visceral fat
  • lack of reliable anatomical markers, poor visualization in surgery
539
Q

best surgery of super obesity

A
  • studies show more initial wt loss with RYGB, but in long-term is comparable to sleeve
  • wt decreases, but BMI still likely to be >40 and will need additional interventions
  • best to add AOBM after surgery to give additional wt loss
540
Q

how to dec diarrhea with metformin

A
  • lower carb
  • lower fat
  • higher prot
541
Q

GLP-1 and fatty liver

A
  • help to dec cholesterol

- dec degree of hepatosteatosis and dec risk for fibrosis

542
Q

key characteristics of genetic variant causing obesity

A
  • hyperphagia (insatiable appetite)

- early onset, severe obesity

543
Q

hyperphagia definition

A
  • insatiable appetite
  • sev preoccupation with food seeking behavior or food
  • heightened and prolonged hunger
544
Q

prader-willi syndrome

A
  • FTT in infancy
  • onset of hyperphagia between 3-15 yrs
  • hyperphagia can continue into adult hood
  • distress and beh issues if denied food
  • short stature
  • GH def
  • hypogonadism
  • severe neonatal hypotonia, poor suck
  • intellectual disability
  • dysmorphic facial features
  • small hands and feet
545
Q

bardet-biedl synd

A
  • wide range of ht, may look fairly normal
  • hypogonadism
  • food seeking and over-eating
  • typically no distress with not being able to have food
  • visual impairment
  • cognitive disability
  • polydactyly
  • renal dysfunction
  • specific criteria to dx: 4 primary or 3 primary and 2 secondary
546
Q

MC4R def

A
  • 1:2000
  • inc lean body mass and accelerated linear growth
  • hyperinsulinemia
  • may have lower BP
  • differing degrees of hyperphagia and obesity depending on genotype
547
Q

PCSK1 def

A
  • persistent diarrhea, intestinal malabsorption, and FTT in infancy
  • hypoglycemia
  • hypothyroid
  • adrenocorticotropic horm def
  • hyperphagia develops after
548
Q

leptin actions in hypothalamus

A
  • activates POMC and AgRP/NPY neurons
  • POMC activates MC4R neurons causing dec hunger, dec food intake, and inc energy
  • AgRP/NPY path act to inhibit POMC signal to MC4R
549
Q

leptin def

A
  • normal linear growth with dec adult ht
  • hypogonadotropic hypogonadism
  • hypothyroid
  • immune abnormalities
550
Q

POMC def

A
  • accelerated childhood growth
  • adrenocorticotropic horm def
  • mild hypothyroid
  • red hair, light skin
551
Q

Alstrom synd

A
  • short stature
  • DM2, insulin resistance
  • hypogonadism
  • hyperandrogenism in females
  • hypothyroid
  • visual impairment
  • hearing loss
  • cardiomyopathy
  • hepatic dysfunction
  • renal failure
552
Q

Tx of genetic disorders

A
  • need multidisciplinary approach
  • if able, tx the actual deficiency
  • can consider other AOM and surgery, but need to address the deficiencies
553
Q

Health related quality of life in peds with obesity

A
  • similar reported QoL to children with cancer

- more at risk if autism and Down’s syndrome

554
Q

mental health risks in peds obesity

A
  • preschool wt that is high increased risk for utilization of mental health services
  • higher weight, higher distress
  • more depression in girls
  • 25% of girls use extreme ways to try to control obesity (ie purging, pills, etc)
  • greater degree of suicidal ideation (but not attempts)
  • feel less smart
  • increased anxiety
555
Q

% children with reported depression

A
  • 54% with significant symptoms

- only 10% report no symptoms

556
Q

white fat structure

A
  • unilocular lipid droplet
  • few mitochondria
  • energy storage
557
Q

brown fat structure

A
  • numerous small fat droplets
  • many mitochondria
  • energy dissipates
  • causes “uncoupling of thermogenesis”
  • found more in younger, women, and more active people
558
Q

beige fat structure

A
  • dissipates energy
  • activity is very inducible
  • present in all adults
  • can be recruited to brown fat and improves insulin sensitivity and utilization
559
Q

how to activate brown fat

A
  • cold
  • NE/epinephrine
  • main fuel is free fatty acids and glucose
  • has lots of beta-3 rec, so also see inc HR and BP when activated
560
Q

CVOT

A
  • cardiovascular outcome trial
  • FDA requires as post-marketing requirement for AOM
  • to get statistical power often recruit older people with heart issues, DM, etc
  • primary composite endpoint is MACE (major adverse cardiac events)
  • designed for non-inferiority trial to placebo
561
Q

qysmia cardiovascular warning

A
  • warning for only phentermine has been withdrawn for qysmia
  • not actually contraindicated in cardiac dz, CVA, CAD, CHF, arrhythmia, heart failure
  • warning was based on MOA not actual clinical trials
  • however, the effect on patients with these conditions has not really been well-established (none reported in drug trials, but no COVT has been done)
562
Q

contrave and cardiovascular dz

A
  • contraindicated in uncontrolled HTN

- effect on cardiovascular M&M not well established

563
Q

AAP recommendation for lipid screening in peds

A
  • screen risk factors at birth
  • starting at 2 y/o if high risk condition
  • universal screening in 9-11 y/o
  • one more screen at 17-21
564
Q

high risk conditions for peds HLD

A
  • DM1 and 2
  • CKD
  • renal transplant
  • postorthotopic heart transplant
  • kawasaki dz with aneurysm
565
Q

mod risk conditions peds for HLD

A
  • kawasaki dz with regressed aneurysm
  • autoimmune dz
  • HIV
  • nephrotic synd
566
Q

lipid screening guideline for 2-8 y/o

A
  • screen if FH MI, CVA, CABG at < 55 y/o males or <65 y/o females
  • parent with TC >240 or known dyslipidemia
  • child with DM, HTN, BMI >95th%, or smoking
  • child with mod/high risk condition
567
Q

peds TC goals

A

<170

>200 is high

568
Q

peds LDL goals

A

<110

>/= 130 is high

569
Q

peds TG goals

A
  • 0-9 y/o <75, >/=100 is highg

- 10-19 y/o <90, >/=130 is high

570
Q

peds HDL goals

A

> 45

<40 is low

571
Q

17-21 y/o TC goal

A

<190, >225 is high

572
Q

17-21 y/o LDL goal

A

<120, >160 is high

573
Q

17-21 y/o TG goal

A

<115

>150 is high

574
Q

17-21 yo HDL goal

A

> 45

<40 is low

575
Q

lipid screening concerns in peds

A
  • no clear benefit
  • may lead to over dx and over-treatment
  • cost
  • treatment unknowns in peds
576
Q

nutrition guidelines for elevated cholesterol in peds

A
  • 25-30% calories from fat
  • <7% saturated fats
  • <200 mg cholesterol
  • plant sterols to replace other fat sources
  • add fiber to diet 6-12 g/day
  • 1 hr mod PA per day
  • <2 h/d screen time
  • dec sugar intake
  • complex instead of simple sugars
577
Q

when to tx HLD with meds peds

A
  • severe primary hyperlipidemia (ie familial)
  • high risk condition
  • evidence of CAD
  • all care should be under lipid specialist
578
Q

how to screen peds for HLD

A
  • use non-fasting lipid panel first

- fasting if non-fasting is near referral/medical tx level

579
Q

endoscopic gastric therapy metabolic effects

A
  • dependent on wt loss
580
Q

endoscopic small bowel therapy metabolic effects

A
  • independent of weight loss
581
Q

small bowel endoscopic therapies for wt loss

A
  • bypass liners (duodenojejunal, gastroduodenojejunal)
  • intestinal bypass
  • duodenal mucosal resurfacing
582
Q

intensity of lifestyle visits and wt loss

A
  • low intensity (<6 in 6 mths) no wt loss
  • mod intensity (6-13 in 6 mths) 5% loss
  • high intensity (>14 in 6 mths) up to 10%
583
Q

obalon balloon system

A
  • swallow capsule
  • filled with nitrogen gas that fills balloon in stomach
  • could allow for in office procedure
  • most use multiple capsules
  • GI removes balloons
  • 30% have heartburn, so if already have not good option
  • less N/V than other intragastric devices
584
Q

travel with intragastric balloons

A
  • can’t be at sea level >3 wks or need to get balloon out

- where lived in relation to where placed matters

585
Q

Aspire aspiration device SE

A
  • hypoK, may need replacement
586
Q

transpyloric shuttle

A
  • tube placed across pylorus with balloon in stomach
  • intermittently blocks pylorus causing delayed gastric emptying
  • keep in 12 mths
587
Q

pill balloon in production

A
  • elipse balloon
  • capsule swallowed and then filled with saline
  • at 4 mths will self-deflate
588
Q

duodenal mucosal resurfacing

A
  • high fat diet actually changes our mucosal lining
  • use hydrothermal ablation of hyperplastic mucosa
  • regrowth is normal mucosa
589
Q

Stop eating CRAP

A
  • carbonated drinks
  • refined sugars
  • artificial foods
  • processed foods
590
Q

Meal order to help with weight loss

A
  • protein
  • veggie
  • carb
591
Q

non-nutritive sweetners

A
  • limit or avoid
  • still cause increase in insulin and obesity
  • may not have calories but still inc weight
  • increased risk for CAD
  • people often use too much and cancels out the other calories they are cutting
592
Q

odds for childhood obesity with early wt gain

A
  • risk higher with very rapid wt gain (crossing of >/= 2 lines)
593
Q

Mothers diet and infant food preference

A
  • flavors from mothers diet may get into breast milk and amniotic fluid
  • can influence food preference in infants later
  • may be more accepting of different foods
594
Q

Restrictive feeding in peds

A
  • may lead to weight gain
595
Q

risk for DM2 in young adults with wt gain

A

30% higher

596
Q

risk for HTN in young adults with wt gain

A

14% higher

597
Q

risk for CAD in young adults with wt gain

A

8% higher

598
Q

SES and obesity

A
  • increased risk if not graduate high school
  • inc risk if low income
  • inc ped risk if family low SES
  • girls in low SES more likely than boys
  • in adults less of a discrepancy with obesity related to income
599
Q

men obesity with SES

A
  • similar between incomes

- higher incomes may actually have more

600
Q

women obesity with SES

A
  • inc in low SES
601
Q

barriers to weight loss in AA women studies

A
  • lack of time
  • access to resources
  • food is sense of pleasure
  • identification with larger body size (cultural)
  • pressure to conform
  • fears about bariatric surgery
  • thinking surgery is too extreme
602
Q

treatment challenges with AA trials

A
  • tend to have less weight loss showing metabolic differences between races
  • great insulin secretion in AA and more insulin resistant
  • can see inc in A1c after surgery
603
Q

inheritability of obesity

A
  • up to 70% heritable

- genes related to CNS function

604
Q

key psychological skills need for wt loss and maintenance

A
  • restraint

- resilience

605
Q

CBT for wt loss

A
  • address problem feeding behavior and emotions
  • replace dysfunctional thinking with helping thinking
  • improves binge eating and depression
606
Q

unhelpful thinking styles

A
  • all or nothing thinking
  • mental filter (only look at certain evidence)
  • jumping to conclusions
  • emotional reasoning
  • labelling
  • over-generalizing
  • disqualifying the positive
  • magnification and minimization
  • use of should or must can make us feel guilty
  • personalization
607
Q

step approach to CBT

A
  • identify thoughts preceding bad behavior
  • label the sabotaging thought ( giving yourself permission to cheat, being self-critical)
  • challenge that thought (is it really true)
  • summarize the evidence to replace with new realistic thought
608
Q

how to build resilience

A

Set expectations:

  • lapses are normal
  • look at other obstacles the pt has overcome
  • address internal bias about weight
  • reiterate obesity as a dz
609
Q

peds obesity and fx risk

A
  • higher wt would think more bone density

- but have inc fx risk

610
Q

obesity impact on bone

A
  • higher volumetric BMD
  • inc cortical thickness and porosity
  • inc trabecular number and thickness
  • inc failure load
  • however, amt of inc is not enough for adaptation to higher wt
611
Q

type of fat and BMD

A
  • positive association with SC
  • conflicting assoc with visceral (likely have worse BMD)
  • ratio of VAT/SAT is important neg predictor for bone outcomes (higher number is worse)
612
Q

mediators of fat relation to BMD

A
  • leptin- inc cortical bone
  • adiponectin- stimulate osteoclast differentiations and effects
  • inflammation stimulate osteoclast activity
613
Q

marrow adipose tissue and BMD

A
  • inverse relationship
  • higher MAT leads to lower BMD
  • more seen in trabecular bone
614
Q

MAT in obesity

A
  • higher MAT, so dec BMD

- DM also inc MAT

615
Q

wt loss surgery and bone

A
  • causes dec BMD and change in architecture
  • likely related to dec leptin, PYY
  • have long-term inc fx risk
616
Q

how breastmilk dec obesity

A
  • role of microbiome from milk
  • less overfeeding
  • self-regulation of intake
617
Q

obesity and breastfeeding

A
  • overweight/obese same likelihood to initiate breastfeeding, but more likely to stop at d/c
  • obese women don’t breastfeed as long
618
Q

obesity and difficulty with breastfeeding

A
  • get dec mammary epithelial gland cells
  • increased adipocyte cells
  • see more flattened breasts, flat nipples
  • higher androgen/DHEA levels in pregnancy make difficulties with breastfeeding
  • inc risk C/S, difficult labors, etc which can disrupt breastfeeding
  • dec milk production with insulin resistance
  • dec prolactin in 1st 48 hrs
  • higher leptin levels which inhibits some oxytocin
619
Q

nutrition for breastfeeding women

A
  • min calories 1500
  • need extra 500 cal when breastfeeding
  • generally avoid ketogenic diets
  • need min 50g carb/day
  • meal replacements okay
  • fasting may be okay
  • do frequent nutritional labs if h/o bariatric surgery
  • may need extra vit D and B12
620
Q

AOM in breastfeeding

A
  • metformin, wellbutrin, and saxenda okay

- avoid topamax, naltrexone and phentermine

621
Q

pediatric characteristics for improved wt loss

A
  • older age >12 y/o
  • greater severity of obesity
  • hispanic
622
Q

peds wt loss and improvement in metabolic

A
  • need 5% wt loss to see improvement in cardio-metabolic risk factors
623
Q

binge eating disorder criteria

A
  • recurrent episodes of binge eating
  • episodes associated with 3 (eating more rapidly than normal, eating until uncomfortable full, eating large amts when not hungry, eating alone b/c embarassed, feeling disgusted in self)
  • marked distress regarding behavior
  • episodes occur at least 1x/wk for 3 mths
  • not associated with compensatory behavior
624
Q

binge eating definition

A
  • eating in discrete period of time amount of food that is larger than most people would eat in that time
  • sense of lack of control over eating
625
Q

overeating vs binge eating

A
  • overeating does come with same amount of distress about the behavior
626
Q

binge eating states

A
  • most common ED
  • affects 1-3% population
  • more in females
  • avg age 15-25
  • 80% have concurrent psych dz
627
Q

night eating syndrome

A
  • recurrent episodes of waking to eat or excessive food consumption (>25% daily calories) after evening meal
  • morning anorexia
  • insomnia
  • tend to be carb heavy foods
  • nocturnal awakenings to eat are common
  • causes impairment and distress
628
Q

night time eating stats

A
  • 1.5% population
  • females have more sev symptoms
  • relapsing/remitting with stressors
  • 15-20% also have BED
629
Q

BED and co-morbidieis

A
  • more sev depression
  • higher BMIs
  • severe OCD
  • sleep problems
  • feel more inadequate or inferior
630
Q

obesity related eating behaviors

A
  • emotional eating
  • binge eating
  • external eating
  • reactivity to food cravings
  • restrained eating
  • mindless eating
631
Q

BED tx

A
  • CBT
  • Dialectical behavioral therapy (DBT) (mindfullness, emotional regulation, distress tolerance)
  • interpersonal therapy
  • normalized eating
  • medications
632
Q

CBT outcomes in BED

A
  • dec binge frequency and days
  • dec depression
  • dec pre-occupation with food
  • no effect on wt
633
Q

Medication to tx BED

A
  • lisdexamfetamine
  • only FDA approved med for mod to sev BED
  • MOA
  • 30 mg/day
  • inc up to 50 mg/da
  • max dose 70 mg/day
  • not used for wt loss, but does lead to wt loss
634
Q

mod BED

A
  • 4-7 episodes/wk
635
Q

sev BED

A
  • 8-13 episodes/wk
636
Q

topamax and BED

A
  • not FDA approved
  • conflicting evidence if improves binging
  • most have wt loss
  • topamax + CBT may work best
637
Q

2nd generation antidepressants and BED

A
  • duloxetine, venlafaxine, wellbutrin, mirtazipine
  • helps with depression and bingeing
  • no change in wt
638
Q

night eating syndrome tx

A
  • CBT
  • SSRI (zoloft shown to help in studies)
  • progressive m relaxation
  • phototherapy
  • normalized eating (regular meal consumption)
  • inc protein
639
Q

healthy at every size approach

A

(HAES)

  • supports health behaviors for all sizes without using wt as a mediator
  • teaches weight inclusivity and body acceptance
  • health enhancement
  • life enhancing movement
  • eating for being
  • respecting yourself
640
Q

issues with wt focused diet and health plans

A
  • cause food and body preoccupation
  • distracts from personal health goals and other health outcomes
  • dec self-esteem
  • contribute to eating disorders
  • make wt stigma
641
Q

Intuitive eating

A

Another name for HAES

  • rejects diet mentality
  • honors hunger
  • make peace with food
  • challenge the food police
  • feel your fullness
  • discover the satisfaction
  • cope with emotions without food
  • respect your body
  • exercise to feel a difference
  • honor health
642
Q

HAES vs diet

A
  • maintain wt
  • improves lipids and BP
  • improves energy expenditure
  • improves eating behaviors
  • inc self-esteem
  • dec depression
  • dec body image issues
643
Q

Bulimia nervosa definition

A
  • recurrent episodes of binge eating
  • recurrent inappropriate compensatory behavior to prevent wt gain
    occur 1x/wk for 3 mths
  • preoccupation with body shape and wt
644
Q

BN stats

A
  • 1-1.5% population
  • more females
  • more in late teens and 20s
  • 1/3 are obese
  • 1/3 with other substance use disorders
645
Q

BN tx

A
  • CBT (combo with SSRI best)
  • DBT
  • fluoxetine (FDA approved)
  • zoloft
  • topamax, trazodone, and zofran are off label
  • DON’t use wellbutrin due to seizure risk
646
Q

meal replacements for weight loss

A
  • lower calorie, but higher protein helps to burn fat and not lose lean mass
  • older products lacked electrolytes and other nutrients so caused issues
647
Q

meal replacements and weight loss

A
  • have more weight loss with combining medication, behavior modification, and meal replacement
648
Q

benefits of meal replacement

A
  • portion and calorie control
  • improved nutrition
  • structured eating
  • simplified food choices
  • avoiding trigger foods
  • protein leverage
649
Q

effects of protein

A
  • dec appetite
  • inc satiety
  • inc thermic effect of food
650
Q

high protein diet content

A
  • 1.2-1.6 g prot/kd/d of IBW

- at least 25-30 g protein/meal

651
Q

meal replacement pros for office

A
  • easy to use
  • good for pt with limited planning
  • good for busy people
  • easy to give structured eating plan
  • revenue can help fund other areas
  • elimination diet
652
Q

VLCD meal replacements

A
  • higher levels of potassium and Na so won’t get low
  • need to use complete product, not just supplement
  • but don’t want total/complete meal product that is NL daily calories which are more for wt maintenance
  • NL use 5 products per day to get daily calories
  • think about adding med to help dec appetite
653
Q

labs on VLCD

A
  • initial, 2 wk, 4 wk, then monthly
  • CMP, mg, Ph
  • will see transient inc in LFTs with wt loss, if >3x ULN may need additional replacement product or regular food
654
Q

VLCD potential pts

A
  • need wt loss for surgery
  • post-surgery wt regain
  • failed other options
  • DM
655
Q

VLCD cautions

A
  • CHF
  • DM
    CKD/ESRD
656
Q

types VLCD products

A
  • bariatric advantage
  • bariatrix nutrition
  • optavia
  • optifast
  • robard
657
Q

malnutrition risks

A
  • restrictive procedures
  • vegetarian
  • lactose intolerance
  • celiac/gluten free
  • food allergies
  • budget, homeless
  • edentulous
  • bowel resection
  • IBD
658
Q

percent iron def after surger

A

30%

659
Q

Anemia not improved by iron, B12, folate

A
  • consider other def like Cu, Zn, Vit A, Vit E
660
Q

lipedema

A
  • “stove pipe legs”
    more nodular fat
  • non-pitting edema
661
Q

painful fat

A
  • dercum’s dz

- adiposis dolorosa

662
Q

lymphedema vs lipedema

A
  • lymphedema also involves dorsal aspect of feet

- lipedema has easy bruising

663
Q

waist to hip ratio for obesity

A

hip measured at superior iliac crest

  • women >0.8
  • male >1:1
664
Q

resting metabolic rate components

A

makes largest portion of daily energy expenditure

  • 15% brain
  • 7% heart
  • 5-10% kidney
  • 25% muscle
  • 4% adipose tiss
665
Q

metabolically healthy with obesity

A
  • MHO

- subset of people with obesity that have no metabolic dz

666
Q

metabolicaly obese, normal weight

A
  • MONW

- NL wt but have metabolic issues

667
Q

who to screen with EKG

A
  • symptomatic
  • cardiac risk factors
  • strong FH
  • medications
  • pre-exercise eval
  • pre-op eval
668
Q

obesity EKG abnormalities

A
  • LAD
  • T waves
  • PACs (OSA)
  • Hypertrophy
  • QT abn
669
Q

secondary obesity w/u

A
  • PCOS
  • hypogonadism
  • cushings
  • hypothalamic/pit
670
Q

who to get screen abd u/s

A
  • NAFLD
  • nephrolithiasis
  • PCOS
671
Q

who get sleep study

A
  • pos screen
  • neck >17 male and 16 female
  • fatigue
  • mallampati 3-4
  • HTN
672
Q

B1 def s/s

A

thiamine

  • wet beriberi (CVD)
  • dry beriberi (neurologic)
  • wernicke-korsakoff synd (ataxia, oculomotor dysfunction, confusion)
673
Q

B2 def s/s

A

Riboflavin

  • anemia
  • mouth/lip/skin disorders
674
Q

B3 def s/s

A

Niacin

- pellagra- dermatitis, dementia, diarrhea

675
Q

B6 def s/s

A

Pyridoxine

  • coordination
  • mental changes
  • oral lesions
676
Q

B9 def s/s

A

Folic acid

  • macroytic anemia
  • glossitits
  • NT defects
677
Q

B12 def s/s

A

Cyanocobalamin

  • macrocytic anemia
  • dementia
  • balance
  • peripheral neuropathy
678
Q

Vit C def s/s

A
  • scurvy
  • bleeding gums
  • poor wound healing
679
Q

calcium def s/s

A
  • osteoporosis
  • osteomalacia
  • poor dentition
680
Q

iron def s/s

A
  • microcytic anemia
681
Q

zinc def s/s

A
  • poor wound healing

- impaired immunity

682
Q

copper def s/s

A
  • anemia
  • leukopenia
  • myeloneuropathy
683
Q

selenium def s/s

A
  • fatigue
684
Q

iodine def s/s

A
  • thryomegaly

- cretinism

685
Q

chromium def s/s

A
  • insulin resistance
686
Q

Loss of control eating disorder (LOC-ED)

A
  • for children <12 who display binge type eating
  • similar criteria to BED
  • assoc with ADHD
687
Q

graze eating

A
  • repetitive and unplanned eating of small amount of food
  • may include sense of loss of control
  • can’t stop or resist eating
  • compulsive disorder
688
Q

wt in BN

A
  • 80% normal weight
  • 10% overweight
  • 10% underweight
689
Q

complications of BN

A
  • perimolysis (tooth enamel erosion)
  • scarring of back of hands
  • swollen salivary glands
  • SI
690
Q

AN criteria

A

Need 3/3

  • restriction of energy intake causing low weight (BMI <18.5)
  • intense fear of gaining weight
  • distorted body image
  • amenorrhea no longer necessary to diagnose
691
Q

Types AN

A
  • restricting type

- binge eating/purging type

692
Q

AN severity

A

Based on BMI

  • Mild BMI >17
  • mod BMI 16-16.99
  • sev BMI 15-15.99
  • extreme <15
693
Q

AN complications

A
  • anemia
  • hypoK, hypoMg
  • metabolic alkalosis
  • amenorrhea
  • osteoporosis
  • inc ventricular to brain ratio
  • abn LFTs
  • impaired renal function
  • death
694
Q

Body dysmorphic disorder

A
  • appearance preoccupations (normally something that wouldn’t really seem abn)
  • repetitive behaviors compulsive beh in respo to appearance concerns)
  • distress/impairment in areas of life
695
Q

BDD tx

A

Most off- label

  • SSRIs
  • CBT
  • topamax
  • lamictal
696
Q

Body image dissatisfaction

A
  • neg thoughts and feeling about body
  • associated with AN and BN
  • tx CBT
697
Q

Risks for OSA

A

Should have in-lab study not HST

  • obesity (BMI >35)
  • pre-op for bariatric surgery
  • high risk occupation
  • CVA
  • CHF
  • DM2
  • Afib
  • refractory HTN
  • nocturnal dysrhythmia
  • pulm HTN
698
Q

mallampatic score

A
  • Class 1- soft palate, tonsills, and uvula visible
  • class 2- soft palate, partial tonsills, and uvula visible
  • class 3- soft palate and base of uvula visible
  • class 4- hard palate visible
699
Q

OSA dx criteria

A
  • AHI >15/hr or 5/hr with symptoms
700
Q

OSA severity

A
  • mild AHI 5-14
  • mod AHI 15-29
  • sev AHI >30
701
Q

obesity hypoventilation syndrome

A
  • obesity BMI >30
  • PaCO2 >45
  • often co-existing OSA
  • serum bicarb often >27
702
Q

Complications OHS

A
  • high mortality
  • pulm HTN
  • R sided CHF
703
Q

Tx shift work sleep disorder

A
  • planned sleep
  • light exposure
  • daytime melatonin
  • daytime hypnotics
  • evening stimulants caffeine, modafinil)
704
Q

Sleep related eating disorder

A
  • 1-5% population
  • 80% have other sleep issue (RLS, PLMS, somnambulism)
  • inc with stress
  • associated with hypnotic use and antipsychotics
705
Q

sleep related eating disorder tx

A
  • remove any offending meds
  • tx associated disorders
  • topamax
  • SSRIs
  • trazodone
  • CPAP if OSA
706
Q

Motivational interviewing RULE

A
  • Resist trying to fix the problem for them
  • Understand their motivation
  • Listen
  • Empower them to make their own decisions
707
Q

Motivational interviewing principles

A
  • express empathy
  • develop discrepancy
  • roll with resistance
  • support self-efficacy
708
Q

Motivational interviewing skills OARS

A
  • open questions
  • affirmations
  • reflections
  • summaries
709
Q

Change talk

A
  • pt’s words that favor movement in the direction of change

- what we try to encourage

710
Q

DARN to show movement towards change

A
  • Desire to change
  • Ability to change (can, could)
  • reasons to change (if… then)
  • need to change
711
Q

Readiness scale

A
  • ask 1-10 how important or read to change

- helps to determine barriers and motivators

712
Q

SMART goals

A
  • specific
  • measurable
  • achievable
  • realistic/relevant
  • timely
713
Q

stages of change

A
  • pre-contemplation
  • contemplation
  • preparation
  • action
  • maintenance
714
Q

pre-contemplation

A
  • no intention to change

- unaware of need to change

715
Q

goal in pre-contemplation

A
  • build self-awareness

- explore ambivalence

716
Q

contemplation

A
  • aware that problem exists

- interest in changing in 6 mths

717
Q

goal in contemplation

A
  • explore pros and cons

- resolve ambivelence

718
Q

preparation

A
  • open to and willing to change in next 30 days
719
Q

goal in preparation

A
  • set small, realistic goals

- develop action plan

720
Q

action

A
  • initiation of change

- committing to goal

721
Q

goal in action

A
  • reward behavior

- social support

722
Q

maintenance

A
  • continued change >6 mths
723
Q

goal in maintenance

A
  • lapse and relapse management

- continued goal setting

724
Q

behavior therapy

A
  • reinforce or extinguish behavior
  • give rewards
  • aversive stimuli
  • restructure environment
725
Q

components of behavior therapy

A
  • self-monitoring
  • stimulus control
  • problem solving
  • goal setting
  • contingency management
  • enlisting social support
  • relapse prevention
  • stress management
  • rewards
  • ongoing contact
726
Q

dialectical behavior therapy

A

Form of CBT

  • focuses on mindfullness, interpersonal effectiveness, emotional regulation
  • uses beh therapy to teach life skills
727
Q

interpersonal therapy

A
  • part of motivational interviewing
  • focuses on resolving mood effects from interpersonal conflicts
  • goal to promote positive interactions with others
  • improves assertiveness
  • helps pt use social supports
728
Q

prevalence obesity among US adults

A

40%

729
Q

prevalence adults overweight or obese

A

70%

730
Q

Adult age most correlated with obesity

A

40-59 y/o

731
Q

cost of obesity

A

As wt increases, cost inc exponentially

  • inc total medical cost
  • inc chronic conditions
  • inc rates of hospitalization
  • inc physician visits
  • inc med use
732
Q

environmental factors affecting obesity

A
  • heavy metals
  • stress
  • poor sleep
  • prenatal influence
  • chemical exposures- BPA, arsenic, chromium
733
Q

most common obesity syndrome

A
  • MC4R syndrome
734
Q

mortality and obesity

A
  • mortality increases 30% for each 5 kg/m2 inc in BMI

- BMI 40-45 dec life by 8-10 yrs

735
Q

change in BP with wt loss

A
  • for each 1 k loss, SBP and DBP dec by 1
736
Q

risk of CHF with inc BMI

A
  • inc 2 fold with BMI >30
737
Q

risk obesity and afib

A
  • every 1 U BMI inc inc risk for afib by 4%
738
Q

risk CVA with obesity

A
  • 1 U inc BMI increases hemorrhagic CVA by 6% and ischemic CVA by 4%
739
Q

NAFLD prevalence in obesity

A
  • 90% in BMI >40
  • 55-75% in BMI >30
  • becoming most common indicator for liver transplant
740
Q

risk depression with obesity

A
  • BMI >30 inc risk 1.5-2x
741
Q

calorie definition

A
  • amt of heat required to raise temp of 1 g H2O by 1 degree C
742
Q

RDA

A

recommended daily allowance

743
Q

AI

A

adequate intake

- used when RDA cannot be determined

744
Q

UL

A

tolerable upper intake level

- highest amt able to not cause toxicity

745
Q

EAR

A

estimated average requirement

- amt estimated to meet requirement of 1/2 needed

746
Q

DV

A

daily value

747
Q

acceptable range for protein

A

10-35%

748
Q

acceptable range for carbs

A

45-65%

749
Q

acceptable range for fat

A

25-35%

750
Q

carb kcal/gm

A

4

751
Q

fat kcal/gm

A

9

752
Q

protein kcal/gm

A

4

753
Q

water kcal/gm

A

0

754
Q

RDA carbs

A

130 g/d

755
Q

RDA fat

A

30 g/d

756
Q

omega 6

A

linoleic acid

757
Q

omega 6 RDA

A

7-17 g/d

758
Q

omega 6 sources

A
  • nuts, seeds
  • vegetable oils
  • safflower and corn oil
759
Q

omega 3 RDA

A

.5-1.6 g/d

760
Q

omega 3 sources

A
  • vegetable oils
  • canola and flax seed oil
  • fish oil
  • fatty fish
  • some meat and eggs
761
Q

saturated fat sources

A
  • animal fat
  • coconut oil
  • palm oil
762
Q

protein RDA

A
  • men 56 g/d

- women 46 g/d

763
Q

protein for wt maintenance

A
  • 0.7-1 mg/kg/d
764
Q

protein for weight loss

A
  1. 2-1.5 mg/kg lean body wt/d

- normally 90-120 g/d

765
Q

essential amino acids

A
  • histidine
  • isoleukcine
  • leucine
  • lysine
  • methionine
  • cysteine
  • phenylalanine
  • tyrosine
  • threonine
  • tryptophan
  • valine
766
Q

respiratory quotient

A
  • use to help predict BMR
  • ratio CO2 produced to O2 consumed
  • can help det which macronutrients are being metabolized
767
Q

% post-bariatric surgery that need parenteral iron

A

20-30%

768
Q

B12 def reasons

A
  • pernicious anemia- autoimmune disorder against IF
  • gastric bypass- loss of parietal cells and IF
  • metformin- dec B12 absorption
  • vegan- inadequate intake B12
769
Q

causes folate def

A
  • unhealthy diet with little fruits/veggies
  • dec absorption (IBD, celiac)
  • genetic disorders
  • meds (phenytoin, sulfasalazine, bacrim, OCP)
  • alcohol
  • tobacco
770
Q

B7 def

A

biotin

  • rare
  • alopecia
  • conjunctivitis
  • dermatitis
  • neuro- depression, hallucinations, paresthesia
771
Q

what absorbed in duodenum

A
  • iron
  • Ca
  • has bile and digestive enzymes
  • neutralizes stomach acid
772
Q

what absorbed in jejunum

A
  • carbs
  • AA
  • many vitamins
  • K
  • Iron
  • Ca
773
Q

what absorbed in ileum

A
  • water
  • K
  • minerals
  • slats
  • fats
774
Q

what absorbed in colon

A
  • Vit K
  • biotin
  • B12
  • thiamine
  • riboflavin
  • water
  • Na
  • Cl
775
Q

what secreted in colon

A
  • K

- bicarb

776
Q

Ca and obesity

A

body fat high in low Ca intake

  • low Ca cause inc PTH
  • inc vit D
  • high intracellular Ca
  • inc lipogenesis and dec lipolysis
  • net effect is inc fat stores
777
Q

ADA exchange non-starchy veggies

A
  • 2g prot
  • 5 g CHO
  • 25 cal
778
Q

ADA exchange protein

A
  • 7 g prot
  • 0-8 g fat
  • 35-100 kcal
779
Q

ADA exchange fat

A
  • 5 g fat

- 45 kcal

780
Q

ADA exchange diary

A
  • 8 g prot
  • 12 g CHO
  • 0-8 g fat
  • 90-150 kcal
781
Q

ADA exchange fruit

A
  • 3 g prot
  • 15 g CHO
  • 60 kcal
782
Q

scale of glycemic index

A
  • low <55
  • med 56-69
  • high >70
783
Q

things that affect glycemic index

A
  • preparation of food- fat, fiber, and acid lower the GI
  • ripeness
  • other foods eaten at same time- if combine high and low GI at same time is better
  • age
  • activity level
  • speed of digestion
  • DM/gastroparesis
784
Q

VLCD vs LCD

A
  • no difference in long-term wt loss

- more complications with VLCD

785
Q

wt loss and lipids

A
  • dec total cholesterol and LDL
786
Q

low carb diet and lipids

A
  • lower TG
  • lower VLDL
  • inc HDL
787
Q

low fat diet and lipids

A
  • more LDL lowering
788
Q

mediterranean diet health benefits

A
  • lower CV mortality

- dec DM2

789
Q

vegan diet benefit

A
  • lower LDL
  • dec CV mortality
  • dec DM2
790
Q

DASH diet benefit

A
  • dec BP
791
Q

higher prot, lower GI benefit

A
  • wt maintenance
792
Q

metabolic adaptation to wt loss

A
  • 10% wt loss causes dec energy expenditure/BMR and inc m efficiency
  • total energy expenditure dec by 20-25%
  • will take 300-400 fewer calories/d to maintain same wt compared to someone who didn’t lose weight
  • persists for years
793
Q

omega 3 types

A
  • ALA
  • EPA
  • DHA
794
Q

how to det g prot

A

g prot/7 = ounces of protein

795
Q

AA that can convert

A

can change within each other

  • methionine/cysteine
  • phenylalanine/tyrosine
796
Q

ghrelin

A
  • most potent hunger hormone
  • stimulated when stomach empty
  • inc hunger and dec energy expenditure
  • inhibited when stomach stretches with eating
797
Q

ghrelin pathway

A
  • stimulated NPY/AgRP in hypothalamus

- travels through vagal n and nucleus tractus solitarius

798
Q

ghrelin in obesity

A
  • have less of a ghrelin drop after eating which causes to remain hungry
799
Q

factors that inc ghrelin

A
  • fasting
  • wt loss
  • stress
  • sleep deprivation
  • genetics/syndromes (Prader willi)
800
Q

factors that dec ghrelin

A
  • meals
  • wt gain
  • leptin
  • sleeve gastrectomy
801
Q

foods and ghrelin suppression

A
  • CHO suppresses that fastest, but faster rebound

- prot suppresses the longest

802
Q

SI hormones for satiety

A
  • CCK
  • GLP-1
  • OXM (oxymodulin)
  • PYY
803
Q

CCK

A
  • made by L-cells of SI
  • sec due to fat and prot
  • short acting
  • stimulates GB contraction
  • slows gastric emptying
804
Q

GLP-1

A
  • made by L cells SI
  • sec due to CHO
  • inc insulin secretion
  • suppress glucagon
  • dec gastric emptying
  • dec appetite
805
Q

GLP-1 levels dec in

A
  • obesity
  • preDM
  • DM2
806
Q

OXM

A
  • made by L-cells SI
  • binds to GLP-1 rec
  • acts like GLP-1
  • being explored as medication
807
Q

PYY

A
  • made by L-cells SI
  • binds to Y2 rec
  • potent appetite suppressant
  • dec gastric emptying
  • being explored as med

Medical Study (20 decks)

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