Obesity and Eating DOs (3 questions) Flashcards
1
Q
How is obesity Dxed?
A
Measure weight, height, waist circumference and calculate BMI
2
Q
BMI: classes of obesity
A
- Class 1: Obese, BMI > 30.0
- Class II : Severe Obesity, BMI > 35.0
- Class III: Morbid/Extreme Obesity > or = 40
3
Q
Obesity classification in Asians
A
Asians obesity classification is lower: BMI 23-24
4
Q
What BMI ranges are eligible for bariatric surgery?
A
- Class II : Severe Obesity, BMI > 35.0
- Eligible for bariatric surgery if medical treatments have failed, and severe life-threatening complications are present
- Class III: Morbid/Extreme Obesity > or = 40
- Eligible for bariatric surgery if medical treatments have failed
5
Q
“heatlhy weight” BMI
A
BMI 18-25
6
Q
“Overweight” BMI
A
BMI 25-30
7
Q
In what populations in BMI misleading?
A
thletes, children, geriatric
8
Q
Waist circumference: high risk if….
A
- Waist circumference > 102cm or 40 inches for men
- Waist circumference > 88cm or 35 inches for women
- Lower values recommended for Asians
9
Q
What can waist to hip ratio be used to assess?
A
- key indicator to cv risk.
- Females have more rounded contours so lower ratio, males more straight ratio, so higher ratio
10
Q
Complications of obesity
A
- Insulin resistance
- Type II DM
- Hypertension
- Dyslipidemia
- PCOS
- Lower extremity joint disease
- Venous stasis
- OSA
- Cancers: Breast, endocrine, in women; prostate, colon in men.
- GI: GERD, gallstones, fatty liver, non-alcoholic steatohepatitis
11
Q
What is the most efficient / effective means to lose weight?
A
- Reducing energy intake
- Creating a 500kcal/day deficit can allow loss of 1lb/week.
- Its much more difficult to increase energy expenditure by 500kcal/wk through exercise
12
Q
Diet review: Ornish vs WWs vs Zone vs Atkins
A
- Ornish- Good. Teaches you to eat healthier w/ real food not processed (digested before food). Expensive to do. Least compliance, most weight loss.
- Weight Watchers- Good compliance. Support groups. Have products.
- Zone- Good compliance. Support Group. Have products.
- Atkins-bad!
13
Q
Efficacy of pharm therapy for wt loss
A
seldom result in greater than 10% weight loss. This is sufficient to reduce medical complications of obesity, but patients may feel disappointed by such a modest amount of loss.
14
Q
Criteria for medications to lose wt
A
- BMI>27kg/m2
- 1 or more conditions likely to improve with weight loss
- Failure of diet and exercise
- Agree to 2-4 wk. trial of making initial changes in diet and exercise before starting medication
- Agree to continued treatment of diet, exercise, behavior modification while on medication
- Agree to periodic follow up
- Premenopausal women able to have children must use contraception
- Consider pregnancy test prior to initiation
- No contraindication to medication
15
Q
FDA approved wt loss meds
A
- Phentermine Hydrochloride (Adipex)
- Phendimetrazine (Bontril)
- Phentermine Hydrochloride/Topiramate (Qsymia)
- Orlista (Alli, Xenical)
- Lorcaserine (Belviq)
16
Q
Off-label drugs used for wt loss
A
- DM: Metformin, Pramlintide (Symlin)
- Antiepileptic: Topomax
- Antidepressant: Wellbutrin
- Naltrexone Bupropion Hydrochloride (Contrave)
17
Q
Gold standard bariatric surgery
A
Roux en Y gastric bypass-Gold Standard, but losing this since sleeve gastrectomy gaining ground.
18
Q
Tx of anorexia nervosa
A
- For emaciated pts. medical monitoring and supervised nutrition rehabilitation
- If pts. refuse to eat, NG tube placed. Continuous feeding better than bolus. Initiate feeding slowly and monitor to avoid refeeding syndrome.
- Psychotherapy, when adequate nutrition restored
- Supplemental vitamin D and calcium
19
Q
What is refeeding syndrome?
A
metabolic complication that occurs when nutritional support is given to severely malnourished patients Metabolism shifts from a catabolic to an anabolic state. Insulin is released on carbohydrate intake, triggering cellular uptake of potassium, phosphate, and magnesium. When the serum concentrations of these electrolytes are reduced, serious complications, such as arrhythmias, can occur.
20
Q
What is the gender ratio for eating disorders?
A
Female to male ratio 3:1
21
Q
What are the cardinal features of anorexia nervosa?
A
- Self-induced weight loss
- Psychological disturbance
- Distorted body image
- Fear of obesity
- Secondary physiological abnormalities
- Result of malnutrition
22
Q
Which features of anorexia were removed in the transition from DSM IV to DSM V
A
requirement to be above 85th percentile
amenorrhea (absence of menstruation for at least 3 consecutive cycles)
- important because this allows to catch more at risk ados!*
- Also - amenorrhea not apply to male / prepuscent / contraception*
23
Q
AN: Subtype restricting vs binge/purge according to DSM-V
A
- Restricting: During the last 3 months, the individual has not engaged in recurrent episodes of binge-eating or purging behavior
- Binge/Purge: During the last 3 months, the individual has engaged in recurrent episodes of binge-eating or purging behavior
24
Q
DSM-V criteria for bulimia nervosa
A
- Recurrent episodes of binge eating
- Recurrent inappropriate compensatory behaviors to prevent wt gain
- The binge eating and compensatory behaviors both occur, on avg, at least once per week for 3 mths (was twice)
- self eval is unduly influenced by body shape and wt
- This disturbance does not occur exclusively during episodes of AN
25
Subtypes of BN (DSMV)
used to be purging and non-purging, but removed for DSM V
26
What are the "compensatory behaviors" associated w/BN, according to DSM-V?
self-induced vomiting; misuse of laxatives, diuretics, or other medications, fasting; or excessive exercise
27
What is constitutes binge eating d/o, according to DSM-V?
A
*Recurrent episodes of binge-eating, characterized by both of the following:*
1. *Eating, in a discrete period of time (e.g. any 2 hr period), an amount of food that is definitely larger than most people would eat in the same situation*
2. *A sense of lack of control over eating during the episode*
B
The binge-eating episodes are associated with 3+ of the following:
1. Eating much more rapidly than usual
2. Eating until feeling uncomfortably full
3. Eating large amounts of food when not physically hungry
4. Eating alone because of being embarrassed by how much one is eating
5. Feeling disgusted with oneself, depressed, or very guilty after overeating
C
Marked distress regarding binge-eating is present
D
The binge-eating occurs, on average, at least 1x/week for 3 months
E
The binge is not associated with the regular use of compensatory behaviors and does not occur exclusively during the course of AN or BN
28
What constitutes ARFID, according to DSM V?
A
Inadequate intake; restricted range of food or calories → weight loss; sensory.
B
Reduced food intake due to emotional disturbance related to eating without concern for body image. Major meal conflicts.
C
Fear of eating related to an actual adverse event (choking, gagging, vomiting)
29
What labs would you order for a suspected eating disorder?
* CBC and platelets, ESR, BUN, CR, electrolytes, LFTs, Ca, phosphate, Mg, albumin, T4, TSH, ECG
* Consider bone mineral density if amenorrheic for \> 6 months
## Footnote
*Hyperchloremic acidosis – are they purging?*
30
What nutritional assessment would you order for a suspected eating d/o?
* 24 hour recall,
* %IBW – utilize BMI 50%ile for **age** (~BMI divide where they are by what 50th should be
* Recent losses or gains
* Can determine degree of malnutrition
31
What are some complications of AN?
* **Fluid and electrolytes:** Dehydration, hypokalemia, hyponatremia, hypophosphatemia, hypomagnesemia, hypoglycemia
* **Cardiovascular**: Sinus bradycardia (sinus arrhythmia), orthostatic hypotension, ventricular dysrhythmias, reduced myocardial contractility, sudden death secondary to arrhythmias, cardiomyopathy secondary to ipecac use, mitral valve prolapse, ECG abnormalities (including low voltage, prolonged QT interval, and prominent U waves), pericardial effusion, congestive heart failure
* **Renal**: Increased BUN, decreased glomerular filtration rate, renal calculi, edema, renal concentrating defect
* **GI**: Delayed gastric emptying, constipation, elevated liver enzymes, superior mesenteric artery syndrome, rectal prolapse, gallstones
* **Hematologic**: Anemia, leukopenia, thrombocytopenia
* **Endocrine or metabolic**: Primary or secondary amenorrhea, pubertal delay, thrombocytopenia euthyroid sick syndrome (low-T3 syndrome), hypercortisolism, decreased serum testosterone level, partial diabetes insipidus, elevated cholesterol level
* **Low bone mass**: Females with anorexia nervosa have reduced bone mass and increased fracture risk
* Neuromuscular: Generalized muscle weakness, seizures secondary to metabolic abnormalities, peripheral neuropathies, syncope in absence of orthostatic hypotension, movement disorders, structural brain changes (MRI studies have demonstrated enlargement of the lateral ventricles and sulci and significant deficits in both gray- and white-matter volumes in the low-weight stages. Increases in sulcal volume and decreases in gray-matter volume may not be fully reversible with weight recovery.)
32
What hematologic lab results are associated w/AN?
Leukopenia, anemia, thrombocytopenia, decreased serum complement C3 levels, decreased erythrocyte sedimentation rate (ESR
33
What chemistry results are associated with AN?
Increased blood urea nitrogen (BUN) concentration, mildly increased serum glutamic-oxaloacetic transaminase and serum glutamic-pyruvic transaminase levels, hypophosphatemia, depressed serum magnesium and calcium concentrations, increased cholesterol, increased serum carotene level, decreased vitamin A level, decreased serum zinc and copper levels.
34
What endocrine changes are associated with AN?
The hormonal changes in AN reflect an adaptive response to malnutrition.
* Thyroid: Normal thyrotropin (TSH), normal or slightly low thyroxine (T4), often low 3,5,3′-triiodothyronine (T3).
* Growth hormone (GH): Decreased IGF-1 levels, normal or elevated GH levels.
* Prolactin: Normal.
* Gonadotropins: Low basal levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH); prepubertal 24-hour LH secretory pattern, blunted response to gonadotropin-releasing hormone.
* Sex steroids: Low estradiol in females (
* Cortisol: Normal secretion on stimulation. Basal levels are within the reference range or occasionally slightly high.
35
What cardiac findings associated with AN?
Electrocardiographic (ECG) changes including bradycardia, low-voltage changes, prolonged QTc interval, T-wave inversions, and occasional ST-segment depression; echocardiographic changes including decreased cardiac size, left ventricular wall thickness; increased prevalence of mitral valve prolapse, and pericardial effusion.
36
What are some GI findings associated with AN?
Usually normal findings on upper GI tract series, with occasional decreased gastric motility; normal findings on barium enema.
37
What are some renal / metabolic changes associated with AN?
Decreased glomerular filtration rate, elevated BUN concentration, decreased maximum concentration ability (nephrogenic diabetes insipidus), metabolic alkalosis, and alkaline urine.
38
Signs of bulimia nervosa
* (a) body weight is usually normal or above normal;
* (b) calluses on the dorsum of the hand secondary to abrasions from the central incisors when the fingers are used to induce vomiting (Russell sign);
* (c) painless enlargement of the salivary glands, particularly the parotids; (d) dental enamel erosion (perimolysis);
* (e) weight fluctuations;
* (f) edema (fluid retention).
39
What are some symptoms of AN?
Cold intolerance, postural dizziness, fainting; early satiety, abdominal bloating, discomfort and pain; fatigue, muscle weakness, muscle cramps; poor concentration.
40
What are some symptoms of BN?
* (a) weakness and fatigue;
* (b) headaches;
* (c) abdominal fullness and bloating;
* (d) nausea;
* (e) irregular menses;
* (f) muscle cramps;
* (g) chest pain and heartburn;
* (h) easy bruising (from hypokalemia/platelet dysfunction);
* (i) bloody diarrhea (laxative abusers)
41
How should treatment of AN and BN be approached?
* Interdisciplinary team approach.
42
What are some medical and nutrition interventions recommended for BN?
* careful medical monitoring, the correction of any medical complications (electrolyte abnormalities), and a structured meal plan to include eating three normal meals a day.
43
What are some psych interventions recommended for BN?
* Psychological intervention: In adults, cognitive-behavioral therapy (CBT) reduces binge eating and purging activity in approximately 30% to 50% of patients.
44
What are some pharm interventions recommended for BN?
* Pharmacologic treatment: Fluoxetine is the only medication approved by the FDA for the treatment of BN and is most effective at a dose of 60 mg daily. A combination of antidepressant medication and CBT appears to be superior to either modality alone.
*
45
Treatment settings for BN?
The majority of adolescents with bulimia nervosa can be treated in an outpatient setting (outpatient clinic or partial hospitalization).
46
Medical and nutritional intervention for AN
Nutritional rehabilitation, weight restoration and reversal of the acute medical complications.
47
Psychological intervention for AN
Includes family psychoeducation, interpersonal therapy, and family therapy. Family-based treatment has been found to be effective in adolescents.
## Footnote
*lecture mentions CBT as being best*
48
Pharmacologic treatment for AN
Fluoxetine does not appear to be effective in treating the primary symptoms of AN. Studies using fluoxetine have shown inconsistent results with respect to preventing relapse in older adolescents. The most common medications used have included the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram. These medications are also useful in treating comorbid depression or obsessive-compulsive disorder (OCD).
49
Treatment settings for AN
Includes inpatient treatment, outpatient treatment, partial hospitalization, and residential treatment
50
Treatment of amenorrhea and low BMD in AN
Weight restoration results in resumption of menses, usually within 3 to 6 months of achieving treatment goal weight. Hormone replacement therapy has not been proven to be effective in increasing BMD. Recommendations include weight restoration, resumption of spontaneous menses, calcium and vitamin D supplementation, and moderate weight-bearing exercise
51
Why would you admit a pt with an ED?
* Hypovolemia/ hypotension
* Severe malnutrition -
* Cardiac dysfunction, arrhythmias, prolonged QT interval
* Bradycardia
* Electrolyte disturbance – hypokalemia, hypoglycemia
* Rapid weight loss despite interventions
* Intractable binge-purge episodes
* Suicidal thoughts or gestures
* Highly dysfunctional or abusive family
* Failure of outpatient therapy
