Obesity Flashcards
What clinical features are suggestive of Cushing’s syndrome?
- Recent rapid weight gain
- Truncal obesity
- Fullness of face (moonface)
- Increased blood pressure
- Glycosuria (associated with insulin resistance)
What signs would be seen on examination that would suggest Cushing’s syndrome?
- Truncal obesity
- Gynaecomastia
- Striae
- Normal body hair distribution
How should we assess obesity in adults?
- Take waist and BMI measurements and determine weight
Assess: - Presenting symptoms
- Underlying causes of being overweight or obese
- Eating behaviours
- Comorbidities (T2DM, hypertension, cardiovascular disease, osteoarthritis, dyslipidaemia, sleep apnoea)
- Risk factors assessed uding lipid profile (BP, HbA1c)
- Patient’s lifestyle (diet and activity)
- Psychosocial distress
- Environmental, social, and family factors, including family history
- Patient’s willingness and motivation to change lifestyle
- Potential of weight loss to improve health
- Psychological problems
- Medical problems and medication
- Role of family and care works in supporting individuals with learning disabilities to make lifestyle changers
What should be done to help a patient reach a healthy weight?
- Offer support depending on the patient’s needs, and be responsive to changes over time
- Praise successes
- Educate patients:
- On the risks of carrying excess weight
- Realistic targets for weight loss
- The distinction between losing weight and maintaining weight loss
- Advise that the change from losing weight to maintenance typically happens after 6-9 months of treatment
- Realistic targets for outcomes other than weight loss, such as physical activity and healthier eating
- Diagnosis and treatment options
- Healthy eating in general
- Medication and side-effects
- Surgical treatments
- Self-care
- Voluntary organisations and support groups and how to contact them
What is the classifications of overweight versus obesity?
Different weight classes are defined based on a patient’s BMI:
- Healthy weight: 18.5–24.9 kg/m2
- Overweight: 25–29.9 kg/m2
- Obesity I: 30–34.9 kg/m2
- Obesity II: 35–39.9 kg/m2
- Obesity III: 40 kg/m2 or more
When do adults need to be referred to tier 3 care?
- Underlying causes of being overweight/obese need to be assessed
- Patient has complex disease tates/needs that cannot be adequately managed in tier 2 (eg learning disabilities)
- Conventional drug treatment has been unsuccessful
- Drug treatment is being considered for a person with a BMI of more than 50kg/m2
- Specialist interventions (such a very-low-calorie diet) may be needed
- Surgery is being considered
Which group of patients should be considered for bariatric surgery?
ALL of the following criteria:
- BMI of 40+, or between 35-40 and other significant disease (T2DM, hypertension) that could be improved if they lost weight
- All appropriate non-surgical measures have been tried but the patient has not achieved or maintained adequate, clinically beneficial weight loss
- Patient has been receiving or will receive intensive management in a tier 3 service
- Patient is generally fit for anaesthesia and surgery
- Patient commits to the need for long-term follow-up
What is the dexamethasone suppression test?
Dexamethasone is an exogenous steroid that causes suppression of the pituitary through negative feedback
- Used to assess the integrity of the hypothalamo-pituitary-adrenal axis
- Dexamethasone binds to glucocorticoid receptors in the pituitary and therefore inhibits ACTH secretion by the pituitary gland
- When testing the adrean function in patients with Cushing’s syndrome, dexamethasone may be administered in low (1-2mg) and/or high (8mg) doses
- Low dose dexamethasone suppresses cortisol production in normal subjects
- High dose dexamethasone suppresses steroid production in pituitary dependant Cushings syndrome - or Cushing’s disease
- It will not reduce steroid production in patients with primary adrenal tumours or in those with ectopic ACTH production
What are the types of results seen in the dexamethasone suppression test?
Normal subject:
- Reduction in cortisol levels following low-dose dexamethasone
Cushing’s disease:
- No reduction in cortisol output after low-dose dexamethasone, but inhibition of cortisol output following high-dose dexamethasone
Adrenal tumour or ectopic ACTH:
- No reduction in steroid production after low or high dose dexamethasone
In patients with high resting cortisol and ACTH levels, but ACTH not being suppressed by dexamethasone, ectopic ACTH should be considered
Which three arteries supple the adrenal gland?
- Superior suprarenal artery arising from the inferior phrenic artery
- Middle suprarenal artery arising directly from the abdominal aorta
- Inferior suprarenal artery arising from the renal artery
The adrenal glands have a very rich blood supply and this accounts for the frequent metastasis of malignancies – such as lung cancer, to the adrenal gland
How is venous blood drained from the adrenal glands?
- Venous blood is drained via the suprarenal veins
- Right suprarenal vein drains into inferior vena cava
- Left suprarenal vein drains into the left renal vein
The adrenal glands have a very rich blood supply and this accounts for the frequent metastasis of malignancies – such as lung cancer, to the adrenal gland
What are the four causes of Cushing’s?
- Iatrogenic
- Pituitary ACTH
- Ectopic ACTH
- Primary adrenal (ACTH independent)
What is Cushing’s disease?
- Cortisol excess
- Caused by Pituitary ACTH producing adenoma
- 70% of adult Cushing’s
- Female:male 3:1 up to 10:1
- Age 25-45
- Incidence 1/100,000 per annum
What are the clinical features seen in Cushing’s?
- Central obesity (fat redistribution)
- Protein wasting (osteoporosis/ myopathy)
- Plethora
- Acne
- Striae (red, purple)
- Hypertension (diastolic >105)
- Oedema
- Hirsutism
- Bruising
- Hypokalaemia
What are clinical features that may be seen in Cushing’s that are not discriminating?
- Generalised obesity
- Oligomenorrhoea
- Headaches
- Abnormal GTT