Obesity

Question 1

Obesity History PRICMCP

Answer 1

P: Weight history: min & max. Onset.

R: does the patient exercise?, eating patterns*** (assess ?Bariatric surgery - what things does the patient need to fix? - binge eating, grazing [snacking undefined quantity/duration], night-time eating, stress-eating), FH, depression, medications, endocrinopathy

C: Cardio (AF, IHD, HTN), Resp (OSA), Gastro (NASH, stones), Endo (DM), Ortho (back pain, OA), psych (social isolation, depression)

M: previous attempts + why failed (important question for assessing ?bariatric surgery). diets tried (successes, failures), has Bariatric surgery been discussed? If so are you willing to make necessary changes required for success long term (i.e. exercise/diet)?

C: how is obesity impacting you - ADLs (cook, shopping, balance, bathing), confidence, depression

P: insight into problems associated with obesity - especially complications. Does he/she have a willingness to address it?

Question 2

Secondary causes of weight gain? (3)

Answer 2

Endocrinopathies: hypothyroidism, Cushing’s, hypothalamic

Depression

Medications: TCAs, antipsychotics, steroids, hypoglycaemics, anticonvulsants (CBZ, valproate)

Question 3

Examinations of obesity

Answer 3

BMI

Waist circumference (level of iliac crest)

Cushing’s? - thin skin, bruising, Buffalo hump, proximal myopathy

No features of hypothyroidism

BP

HR - irregularity

Fundoscopy - hypertensive changes?

Mallampati

Features of pulmonary HTN

Features of diabetes complication: PN.

Question 4

The severity of obesity based on BMI?

Answer 4

30-35 obesity (moderate), 35-40 (severe), >40 v. severe

i.e. no mild.

Question 5

What is abnormal weight circumference?

Answer 5

>94 in men

>80cm in women

Question 6

What is your approach in managing this patient’s obesity?

Answer 6

Acknowledge: This is a difficult Mx problem that requires long-term FU, MDT care and patient motivation.

Realistic goals: 5-10% weight loss in 12 months then focus on maintenance.

A: Screen & treat secondary causes: underlying depression, hypothyroid, Cushing’s, hypogonadism, PCOS, rationalize medications - reduce steroids

Screen for complications & treat: baseline ECG (AF/ischaemic changes), fasting glucose, lipids, HBA1C. Guided by symptoms: sleep study, XR spine/hip/knees, USS liver.

T: non-pharm

• Educate: CVS risk, morbidity, mortality
• Diet: aim to decrease caloric intake (<1200), reduce fat, carb, involve dietician.
• Mediterranean diet: shown to reduce CV risk → olive oil, fish, fruit & veg based.
• Meal substitute (VLED drinks) or pre-made (balanced) delivered meals
• Exercise: incidental, 30min 3-5/week → gradually increase, aim 60min/d. Pedometer - monitor number of steps/day (need >10,000 steps for weight loss).
• Count calories, weight diary, phone app with reminders & motivation
• Enroll patient in the weight loss program

T: Pharm

• Orlistat: warn steatorrhoea, very expensive.
• Phentermine (Duromine): sympathomimetic, suppresses appetite, contraindicated if CV disease
• Topiramate: appetite suppresant
• Diabetics: use weight neutral/negative agents (e.g. Liraglutide or Exanatide)

T: Bariatric Surgery

• Indicated in this case? (BMI >40 or >35 with significant comorbidities - OSA, DM, HTN)
• Only after appropriate non-surgical weight loss measures have failed
• Assess operative risk: CV, OSA, resp

Involve: GP, family for ongoing support, encouragement, review. Consider referral to metabolic clinic - dietician, PT, endocrinologist.

Complication & ensure follow-up

• Mood
• Motivation
• Weight progress
• Complications

Question 7

What pharmacologics do you know of for obesity (3)? and side effects?

Answer 7

Orlistat (steatorrhoea, incontinence, $$$)

Phentermine: tachycardia, arrythmia, HTN, PHTN hence contraindicated if CVD

Topiramate (centrally acting - confusion, agitation, fatigue)

Question 8

When is the Bariatric surgery indicated?

Answer 8

BMI >40

or BMI >35 with significant complication/comorbidities

Question 9

Types of Bariatric surgery? (4)

Answer 9

Restrictive: lap gastric banding

Malabsorptive: biliopancreatic diversion, jejunoileal bypass, sleeve gastrectomy

Question 10

What monitorings (2) are required for patients who had bariatric surgery?

Answer 10

1. Bariatric surgery causes nutritional deficiency so these must be monitored
2. Can worsen NASH flare

Approach:

Monitor: Fat-soluble vitamins (ADEK), iron studies, B12, folate, vitamin D + LFTs

Offer supplements: Multivitamins (incl. trace elements), Vitamin D, Thiamine, B12, Iron.

Question 11

What are contraindications to Bariatric surgery?

Answer 11

1. The patient must be willing to make the necessary lifestyle & diet changes post-operatively for a sustainable weight loss: if NO for any reason, would be a contraindication.
   - Untreated major depression or psychosis
   - Alcohol & substance abuse
   - Significant cognitive impairment
   - History of poor adherence
2. Severe Cardiorespiratory disease with prohibitive anesthetic risks

Question 12

What is your approach to assessing this patient for Bariatric surgery?

Answer 12

1. Psychosocial assessment: is the patient willing & equipped to make necessary lifestyle changes? Screen for undiagnosed depression/psychosis/cognitive impairment/substance use. Assess family support.
2. Cardiovascular assessment: Symptoms, ECG (baseline), TTE if symptoms, ECG changes or have been on medications (e.g. Fenfluramine for weight loss).
3. Respiratory: screen for OSA: Questionnaire - STOP-Bang → PSG to confirm → if mod-sev OSA get PFT
4. Gastro: if hepatomegaly O/E, work-up to evaluate Cirrhosis (NAFLD).