Obesity and Diabetes Flashcards
Obesity
Major worldwide health problem
Defined BMI > 30 kg/m² - also consider muscle mass
Discuss diet/exercise at each visit
Ask health goals, what are they doing to meet their goals, do they need help meeting their goals
Consider referral to a dietitian
Consider weight loss medications
Consider referral to a bariatric specialty center
BMI
Underweight- <18.5 Normal 18.5-24.9 Overweight- 25.0-29.0 Obese- 30.0-40.0 Extreme Obese- >40
Diets
Restricted carbohydrate diets (Atkins, Keto)
May be difficult to sustain long-term, tends to have a higher overall weight loss (especially initially)
Low fat diets
Tends to be higher fiber, good for heart disease
Low calorie diets (weight watchers, fasting)
More effective than low fat
Multiple other diets – Mediterranean & DASH highly rated
Exercise
Exercise should always be recommended if patient is healthy enough for participation
Exercise alone results in lower weight loss than when combined with diet
60-90 minutes of moderate intensity exercise daily
Usually cardiovascular exercise is most effective
Strength training can aid in long-term goals and improvement in body shape (losing inches)
Weight Loss Medications
Check current medication list for those than may cause weight gain and/or interactions
Generally for those with BMI > 30 or > 27 with medical conditions
Orlistat (Alli) – blocks absorption (OTC)
May cause flatulence, fatty stool, increased stool, incontinence
Lorcaserin (Belviq) – activates specific receptors (controlled)
Caution in heart disease, may lose 5% of body weight
Liraglutide (Saxenda) – GLP-1 (injectable)
High GI side effects, may lose 5-10% body weight
Phentermine/topiramate (Qsymia)
High number of CNS side effects, may lose 5-7%
Bupropion/naltrexone (Contrave) – decrease appetite
May have strange dreams, insomnia, may lose 5%
Phentermine (controlled)
Can only be used in the short term
Other drugs used off-label
Methylphenidate, zonisamide, octreotide, metformin, Victoza, bupropion, Topamax
Bariatric Surgery
Lap Band (Restrictive)
Average loss 40-50% excess body weight, high complication rate
Gastric Sleeve (Restrictive)
Average loss of >50% excess body weight
Gastric Bypass (Restrictive/Malabsorptive)
Average loss of 60-80% excess body weight
Duodenal Switch (Malabsorptive)
Average loss of >70% excess body weight long-term
Risks of surgery
Dumping syndrome, dehydration, N/V, constipation, obstruction, gaining weight back or failure to lose weight, plus normal risks of all surgeries (PE/DVT, pneumonia, death, etc.)
Long-term Monitoring after Bariatric Surgery
After bariatric surgery (generally lifelong):
Daily vitamins – MVI, Vitamin D, Calcium, Vitamin B12
Healthy lifestyle choices – diet/exercise, high protein diet
Fluid intake 64 ounces or more daily
No NSAIDs, may require PPIs long-term
No smoking, restricted alcohol (absorption changes)
No eating/drinking together, avoid soups
No carbonated beverages, avoid straws
Should have yearly:
CBC, CMP, Thyroid panel, Lipid panel, Iron panel, Vitamin B12, Folic Acid, Hemoglobin A1c, Ferritin, Magnesium, Phosphorus, Vitamin D, Thiamine, Vitamin B-1, RBC-Folate
Type 2 Diabetes Mellitus
Diabetes type 2 is characterized by sufficient circulating endogenous insulin, resistance to insulin action and an inadequacy of compensatory insulin secretion response (Dunphy, 2013).
Insulin resistance in target tissues, abnormal insulin secretion and decreases in insulin receptors causes unique propensities for microvascular and macrovascular complications (Hollier & Hensley 2011).
Significant morbidity and mortality are realized as a result of type 2 diabetes. Complications from this disease are seen most notably in the eyes, kidneys, nerves and heart (Khavandi et al., 2013).
T2DM Pathophysiology
Type 2 DM is associated with 2 abnormalities: insulin resistance and impaired insulin secretion.
As insulin resistance increases, insulin levels begin to rise but the glucose level remains normal. This causes a state of hyperinsulinemia.
The compensatory hyperinsulinemia fails to keep pace when the blood glucose begins to rise.
There is a decline in the endocrine function of pancreatic beta cells. This impairs insulin secretion in response to glycemic load- which produces elevated plasma glucose levels .
T2DM Screening
Testing should begin at age 45
Repeat screening at 3-year intervals for normal results
Early screening should be done for people with BMI 25 or higher and with 1 or more risk factors for diabetes
Lab tests measuring glucose levels-most common test to measure diabetes
T1DM Signs and Symptoms
Poluria- increased urination
Polydipsia- increased thirst
Polyphagia- increased hunger
Weight loss despite increased appetite Fruity breath odor Fatigue, lethargy, drowsiness Confusion, stupor, unconsciousness Nocturnal enuresis Dehydration Increased frequency of infections Rapid onset Insulin-dependent Familial tendency Peak incidence from 10-15 years
T2DM
3 P’s Polydipsia, polyphagia, polyuria
Sudden onset T1dm
Fatigue/Lethargy/Drowsiness Confusion or stupor or unconsciousness Obesity Blurred vision Peripheral neuropathy Ketones in the urine Infection (candida, UTI, skin, balanitis) Hyperglycemia on Chemistry, glycosuria Skin tags, Acanthosis nigricans
Risk Factors for T1DM
Family history of T1DM / Genetics Caucasian, Non-Hispanic Viral exposure (Enterovirus, EBV, CMV, Coxsackievirus, and Mumps) Exposure to cow’s milk during infancy/childhood Vitamin D Deficiency High socioeconomic status Obesity Other autoimmune disease (Grave’s disease, Addison’s disease, Hashimoto’s thyroiditis, Multiple Sclerosis, and pernicious anemia). Perinatal factors: -Maternal age < 25 at time of birth -History of preeclampsia -Neonatal jaundice -Respiratory infection at birth
Risk Factors for T2DM
Family history
Ethnicity: AA, Hispanic, Native American, Asian American, Pacific Islander
Age greater than 45 years
Impaired fasting glucose
Hypertension, physical inactivity
Obesity, PCOS
Hyperlipidemia: HDL < 40 in men and <50 in women
Delivery of a baby > 9 lbs
A1C
- Normal
- Prediabetes
- Normal
Normal- about 5
Pre- 5.7-6.4
Diabetes- 6.5 or above
