Obesity as Chronic Disease Flashcards
(93 cards)
1
Q
Obesity = impaired _____
A
function
2
Q
There are > ___ comorbid conditions &
affects quality & quantity of life that can be associated with obesity
A
160
3
Q
Obesity in adolescents has increased from ↑ 5% to 17% in what timeframe?
A
the last 25 years
4
Q
Obesity % in Developed vs. Developing countries
A
~23% in developed vs. ~13% in developing
5
Q
T/F Obesity is higher with cesarean sections and bottle feedings vs. breast feeding
A
T
6
Q
___% of obese children will become obese adults
A
80
7
Q
What is the cause of obesity?
A
Combination of socioeconomic, genetic, & biologic factors
↑ Calories, ↓ Activity, & Genetic/Metabolic predisposition
8
Q
T/F Inheritance of obesity is usually Mendelian
A
F
9
Q
“obesity gene”
A
ob gene
10
Q
Leptin
A
(Greek leptos, “thin”) is one of several appetite-suppression hormones
11
Q
how does the ob gene relate to leptin?
A
if someone has the ob gene → increase leptin in adipocytes (also secreted by the stomach)
12
Q
Normal function of leptin
A
- Negative feedback signal
- Signals hypothalamus
- Alters the expression of neuroendocrine peptides that regulate energy
intake/expenditure
↓ dietary intake & fat storage
↑ energy expenditure & carbohydrate metabolism
13
Q
Set-Point Theory
A
There is a control system built into every person dictating how much adipose tissue s/he should carry
A “thermostat” for body fat
14
Q
Successfull weight loss according to set point theory
A
Successful weight loss within this theory is to lower the set point as opposed to just having a caloric deficit
Patients MUST be educated about losing consistent weight over time as opposed to losing a large amount of weight quickly (yo-yo effect)
Goal = 5-10% of body weight over 6-12 months
15
Q
Obese individuals often have a form of functional “___”
A
Leptin resistance
16
Q
The argument for how genetics is involved in obesity
A
Famine prevents obesity in even the most obesity-prone individual
↑ prevalence of obesity in the US is far too rapid to be due to changes in the gene pool
17
Q
The Four Horsemen of the Diabesaclypse
A
Soda
Frozen dairy
Pastries
Fast food
18
Q
RISK FACTORS OF
OVERWEIGHT & OBESITY
A
Older age
Lower socioeconomic status in developed countries
Physical inactivity
Stress & other mental illnesses
Disordered sleep (<6 hours/night)*
Childhood obesity
19
Q
Obese individuals have ____% of the risk of developing T2D
A
60
20
Q
Obese indidividuals have >___% of hypertension and coronary heart disease risk
A
20
21
Q
There are >____ complications that can occur from obesity
A
200
22
Q
PEDIATRIC OBESITY DIAGNOSIS
A
BMI for age from 85th to 95th percentiles indicates overweight
BMI for age > 95th percentile indicates obesity
BMI for age > 99th percentile indicates severe obesity
23
Q
ADULT OBESITY DIAGNOSIS criteria
A
BMI 18.5-24.9 indicates normal weight
BMI 25-29.9 indicates overweight
BMI 30-34.9 indicates obesity, class I
BMI 35-39.9 indicates obesity, class II
BMI >40 indicates obesity, class III (morbid)
BMI ≥ 50 indicates “super obese”
24
Q
OTHER TESTING for Obesity
A
- Lipid profile → identify hyperlipidemia
- FBG or OGGT to identify prediabetes or DM
- Liver enzymes → nonalcoholic steatohepatitis (NASH)
- CBC
- Polycythemia may be seen with alveolar hypoventilation syndrome with resulting right heart failure
- Thyroid-Stimulating Hormone (TSH) → hypothyroidism
25
The USPSTF recommends that clinicians offer or refer adults with a body mass index (BMI) of 30 or higher to _____
intensive, multicomponent behavioral interventions
26
Rx for ↓television/screen time recommending
SWAP ENJOYABLE ACTIVITY FOR SEDENTARY TIME
27
TREATMENT & PREVENTION STRATEGIES that address the family as well, not just the child
Eat meals as a family in a fixed place & time
Use small plates & keep serving dishes away from the table
“Plate” food then bring it to the table
Address the family, NOT just the child
28
What is healthy eating?
Nutrient rich, calorie poor
29
ORLISTAT MOA
Inhibits gastric & pancreatic lipases in the lumen of the stomach & intestine
Makes them unavailable to hydrolyze dietary triglycerides into absorbable fatty acids & monoglycerides.
Inhibits dietary fat absorption by ~30%
30
Orlistat Indication
FDA-approved medication for weight loss in obese adults & the only one for adolescents aged 12-16 years old, in addition to multidisciplinary lifestyle weight loss programs
FDA approved for long-term use
31
Finer et al Trial Highlights for Orlistat
12 months, 228 participants
120 mg TID
≧ 5% weight loss (35 v 21%-placebo)
≧ 10% weight loss (28 v 17%-placebo)
32
XENDOS Trial Highlights for Orlistat
4 years, 3,305 participants
Mean weight loss (5.8 kg v 3.0 kg-placebo)
Incidence of DM II (6.2 v 9.0%-placebo)
↓ Impaired Glucose Tolerance
33
ORLISTAT Contraindications
Cholestasis
Chronic malabsorption syndrome
Hypersensitivity to orlistat
contraindicated during pregnancy; safety in lactation unknown
34
Side effects of Orlistat
GI: oily spotting, flatus with discharge, fecal urgency, fecal incontinence
- Small study (~100 pts) showed ↓ S/S by ↑ fiber intake
psyllium husk & ↓ dietary fat
Send them for dietary counseling first
35
Pearls for taking cyclosporine or levothyroxine with Orlistat
If used with orlistat, take cyclosporine 3 hours after the orlistat dose.
If used with orlistat, take levothyroxine 4 hours before/after the orlistat dose.
36
NALTREXONE/BUPROPION (CONTRAVE) MOA
- Not fully understood
- Naltrexone, an opioid antagonist & bupropion, an aminoketone antidepressant (↓ reuptake of dopamine & norepinephrine)
- Regulate food intake by ↑ the firing rate of the hypothalamic pro-opiomelanocortin neurons (appetite regulatory center) & the mesolimbic dopamine circuit
(reward center)
37
COR (Contrave Obesity Research) I Trial Highlights
≧ 10% weight loss (21% v 7%-placebo)
38
COR II (Contrave Obesity Research) Trial Highlights
≧ 10% weight loss (28% v 6%-placebo)
39
COR-BMOD Highlights (Contrave + Behavioral modification)
≧ 10% weight loss (35% v 21%-placebo)
40
COR-Diabetes highlights
≧ 10% weight loss (15% v 5%-placebo)
41
NALTREXONE/BUPROPION (CONTRAVE®)
contraindications
- Acute opiate withdrawal, allergy to bupropion or naltrexone, concomitant use of chronic opioids
- Any patient undergoing abrupt discontinuation of alcohol, benzodiazepines, barbiturates, or antiepileptic drugs
- Bulimia or anorexia nervosa (↑ risk of seizure)
- Concomitant use of bupropion or bupropion-containing products
Concomitant use of an MAOI, including linezolid or IV methylene blue, or use within 14 days of MAOI discontinuation
42
Side effects of NALTREXONE/BUPROPION (CONTRAVE®)
Constipation (19.2%)
Diarrhea (7.1%)
Nausea (32.5%)
Vomiting (10.7%)
Xerostomia (8.1%)
Dizziness (9.9% )
Headache (17.6% )
Insomnia (9.2% )
Anxiety (4.2% )
43
Adverse effects of NALTREXONE/BUPROPION (CONTRAVE®)
HTN (3.2% )
↑ HR
MI (<2% )
Hypoglycemia
Cholecystitis (2%)
Hematochezia (<2%)
Intervertebral disc prolapse (<2%)
Amnesia (<2%)
Angle Closure Glaucoma
Pneumonia (<2%)
44
NALTREXONE/BUPROPION (CONTRAVE®)
Follow up/monitoring
↓ baseline body weight indicates efficacy within 12 weeks
Blood glucose in DM II
Renal function in elderly patients
Suicidality, or unusual changes in behavior
Blood pressure & pulse
Bipolar disorder; baseline screening
45
NALTREXONE/BUPROPION (CONTRAVE®)
PEARLS
Report S/S of suicidal ideation, depression, mania, hypomania, or atypical thinking & behavior
report seizures or tachycardia
Report symptoms of acute hepatitis
Report symptoms of angle-closure glaucoma
Limit or avoid alcohol
Potentially inappropriate medication in the elderly
46
Black Box Warning of Naltrexone/Bupropion
increase or emergence of suicidal ideation, depression, mania, hypomania, or atypical thinking & behavior
47
PHENTERMINE/TOPIRAMATE XR COMBINATION (QSYMIA®) MOA
↑ hypothalamic release of catecholamines, & ↓ appetite/food consumption
Topiramate
unknown, it appears to suppress appetite & enhance satiety
Schedule IV
FDA approved for long-term use
Safety not established <18 yo
48
PHENTERMINE/TOPIRAMATE XR COMBINATION (QSYMIA®)
EQUIP Trial Highlights
≧ 10% weight loss
3.75/23 mg (18.8 v 7.4%-placebo)
15/92 mg (47.2 v 7.4%-placebo)
49
PHENTERMINE/TOPIRAMATE XR COMBINATION (QSYMIA®)
CONQUER Trial Highlights
≧ 10% weight loss
3.75/23 mg (37.3 v 7.4%-placebo)
15/92 mg (47.6 v 7.4%-placebo)
50
PHENTERMINE/TOPIRAMATE XR COMBINATION (QSYMIA®) contraindications
Use with MAOIs or within 14 days of discontinuation of MAOI
glaucoma
hypersensitivity or idiosyncrasies to sympathomimetic amines
hyperthyroidism
pregnancy
51
PHENTERMINE/TOPIRAMATE XR COMBINATION (QSYMIA®) adverse effects
Seizure, angle-closure glaucoma
Acute myopia
Suicidal behavior (0.43%)
Hypohidrosis
52
PHENTERMINE/TOPIRAMATE XR COMBINATION (QSYMIA®) common adverse effects
Constipation (8-16%)
Altered taste (1-9%)
Xerostomia (7-19%)
Dizziness (3-8.6%)
Insomnia (5-9%)
Paresthesia (4-20%)
Nasopharyngitis (9-12.5%)
URI (12-16%)
53
Is PHENTERMINE/TOPIRAMATE XR COMBINATION (QSYMIA®) safe in pregnancy?
Contraindicated during pregnancy
Individuals of Reproductive Potential
(-) pregnancy test before starting, then q month
♁ pts: use effective contraception during treatment
54
PHENTERMINE/TOPIRAMATE XR COMBINATION (QSYMIA®) PEARLS
May ↓ visual acuity &/or cognition. Avoid activities requiring clear vision, mental alertness, or coordination until drug effects are realized.
May impair heat regulation.
55
LORCASERIN (BELVIQ®)
FDA Approval Rescinded 2/23/2020
Post marketing trial showed increased rates of lung & pancreatic cancer
56
TIRZEPATIDE (MOUNJARO®) MOA
Dual glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor agonist
“Twin-cretin”
57
TIRZEPATIDE (MOUNJARO®) GIP and GLP-1RA mechanisms
GIP – incretin hormone, induces insulin secretion with meals
- Hyperosmolarity of glucose in the duodenum
GLP-1RA – ↑ insulin secretion in the presence of ↑ blood glucose
- suppresses glucagon postprandially
- delays gastric emptying → ↓ postprandial glucose
↓ glucagon secretion
58
Contraindications of Mounjaro
Contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with multiple endocrine neoplasia syndrome type 2 (MENS2)
Caution
Hypoglycemia (c/ basal insulin) (14-19%)
Nausea (12-18%)
Diarrhea (12-17%)
Vomiting (5-9%)
Dyspepsia (5-8%)
Constipation (5-7%)
59
TIRZEPATIDE (MOUNJARO®) Serious adverse effects
- Personal or family history of MTC or in patients with MENS 2
- Gastroparesis
- Acute kidney injury
- Delays gastric emptying
- Impacts oral absorption of medications
60
Is TIRZEPATIDE (MOUNJARO®) safe in pregnancy?
Contraindicated during pregnancy
61
PEARLS of TIRZEPATIDE (MOUNJARO®
Advise patients using oral hormonal contraceptives to switch to a non-oral contraceptive method, or to add a barrier method of contraception
Give missed dose within 96 hr
May inject tirzepatide & insulin in same region, not adjacent to each other
62
SEMAGLUTIDE (WEGOVY®) MOA
Glucagon-like Peptide-1 Receptor agonist
↑insulin release with ↑ blood glucose
↓ glucagon secretion (glucose-dependent)
Delay gastric emptying → ↓rate of postprandial glucose levels.
↓ appetite & calorie intake
Weight reduction effect is due to decreased calorie intake
Approved 12 years old & up
63
SEMAGLUTIDE (WEGOVY®) contraindications
- hypersensitivity to drug/class/component
pregnancy
- medullary thyroid CA or family hx
- multiple endocrine neoplasia syndrome type 2
- suicidality hx
- suicidal ideation
64
SEMAGLUTIDE (WEGOVY®) serious adverse effects
C-cell hyperplasia of thyroid
Medullary thyroid carcinoma, papillary thyroid carcinoma (animal studies )
hypersensitivity rxn
Anaphylaxis
Angioedema
Acute kidney injury
Chronic renal failure exacerbation
Pancreatitis
Cholelithiasis
Cholecystitis
Syncope
65
SEMAGLUTIDE (WEGOVY®) Common adverse effects
Nausea (44%)
Diarrhea (30%)
Vomiting (24%)
Constipation (24%)
Abdominal pain (20%)
Headache (14%)
Fatigue (11%)
66
Is SEMAGLUTIDE (WEGOVY®) safe in pregnancy?
Contraindicated during pregnancy
Possibly unsafe in lactation
67
SEMAGLUTIDE (WEGOVY®) PEARLS
Avoid dehydration, esp. with persistent diarrhea or vomiting, to prevent acute renal failure or worsening of renal function
Never share pens
Report S/S of a thyroid tumor, cholelithiasis, or pancreatitis
Monitor for S/S of hyper-hypoglycemia
HR increased (mean 1-4 bpm); 10-19 bpm (41%); 20 bpm (26%)
68
After 68 weeks, semaglutide cut the calculated risk for possible future development of type 2 diabetes in study participants by > ___%
50
69
LIRAGLUTIDE (SAXENDA®) MOA
Acylated human Glucagon-Like Peptide-1 (GLP-1) receptor agonist.
↑insulin release in the presence of elevated glucose concentrations, ↓ glucagon secretion in a glucose-dependent manner, & delay gastric emptying, ↓rate of postprandial glucose levels.
↓ appetite & calorie intake
Safety not establish under 18 yo
70
LIRAGLUTIDE (SAXENDA®) contraindications
Hypersensitivity to liraglutide or any component of the product
Personal or family history of medullary thyroid carcinoma
Personal of family history of multiple endocrine neoplasia syndrome type 2
Pregnancy, in patients treated for obesity
71
LIRAGLUTIDE (SAXENDA®) Serious adverse effects
Breast cancer (0.6% )
C-cell hyperplasia of thyroid
Medullary thyroid carcinoma, papillary thyroid carcinoma (0.2% )
Cholecystitis (0.6% )
Acute renal failure
Angioedema
Cholelithiasis (1.5%)
Colorectal cancer (0.1% - 0.5% )
Pancreatic cancer
Pancreatitis (0.3% )
Anaphylaxis
Suicidal thoughts (0.2% )
72
LIRAGLUTIDE (SAXENDA®) common adverse effects
Hypoglycemia
monotherapy, 9.7 - 23%
combo therapy, 3.60-43.6%
Nausea (39.3% )
73
Is LIRAGLUTIDE (SAXENDA®) safe in pregnancy?
No
74
LIRAGLUTIDE (SAXENDA®) Pearls
Avoid dehydration, esp. with persistent diarrhea or vomiting, to prevent acute renal failure or worsening of renal function
Never share pens
Report S/S of a thyroid tumor, cholelithiasis, or pancreatitis
Monitor for S/S of hyper-hypoglycemia
75
STIMULANT AGENTS MOA
Similar pharmacologic activity to amphetamines
Weight loss mechanism of action unknown
Stimulates the CNS → ↓ appetite & ↑ blood pressure
76
STIMULANT AGENTS Indication
Indicated for short-term weight loss only
77
STIMULANT AGENTS contraindications
Agitation, CVD, HTN, stroke, CAD, arrhythmias, CHF
Use with MAOIs; at least 14 days should elapse between use & an MAOI
History of drug abuse
Glaucoma, hyperthyroidism, nursing or lactating women, pregnancy
78
STIMULANT AGENTS Serious Adverse effects
Cardiomyopathy
Heart valve disorder
Heat stroke
Cerebral hemorrhage
Cerebral ischemia
Psychotic disorder
Primary pulmonary hypertension
Myocardial ischemia
Rhabdomyolysis
79
STIMULANT AGENTS Common Adverse effects
Xerostomia, nervousness, insomnia, irritability
↑ BP (Mild), palpitations (Mild), rash, urticaria, constipation, nausea, stomach cramps, vomiting, xerostomia, CNS stimulation, dizziness, HA, insomnia, pain, blurred vision, mydriasis, restlessness
80
Are STIMULANT AGENTS safe in pregnancy?
No
81
STIMULANT AGENTS PEARLS
Do not take during or within 14 days following discontinuation of MAO inhibitor use.
Avoid activities requiring mental alertness or coordination until drug effects are realized
Report ↓ in exercise tolerance, or S/S of primary pulmonary hypertension (dyspnea, angina, syncope, lower extremity edema).
Avoid using concomitant weight loss medications
Avoid SSRIs
Avoid alcohol
82
Weight loss medication may be considered in adolescents if:
- BMI ≥ 95th percentile for age with comorbidities or
- BMI > 35 & there is no improvement or worsening of BMI after 6-12 months of multidisciplinary lifestyle weight loss programs
- BMI ≥ 95th percentile for age without obesity-related risk factors or diseases & there is no improvement in BMI or BMI percentile after office-based family-centered weight loss plan for 6-month & comprehensive multidisciplinary weight loss program with peers
83
SURGICAL OPTIONS for Obesity
Bariatric surgery for obesity
25-33% total weight loss
Maintained long-term
Only 1% of US patients receive the procedure
84
LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS
Creates a proximal gastric pouch of small size (~20 mL) separate from the distal stomach.
A Roux limb of proximal jejunum is brought up & anastomosed to the pouch
\
85
Bariatric Outcomes Longitudinal data
2 years post op → ~ 70 – 75% of that weight in excess of a patient's ideal body weight.
5 years post op → ~ 60 – 70% of the excess weight
86
STAMPEDE Trial (Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently) data
80% of DM II patients maintained HbA1c <7%
Pts without DM were ~92% less likely to develop DMII compared to non-surgical pts
87
SLEEVE GASTRECTOMY
- Creates an elongated gastric tube that remains in continuity with the pylorus & duodenum
- Resected gastric remnant is removed
- ↑ efficacy but ↑morbidity than adjustable gastric banding
- ↓ efficacy but ↓ morbidity than Roux-en-Y gastric bypass
88
BILIOPANCREATIC DIVERSION Procedure
Resection of the distal 1/2 to 2/3 of the stomach & creation of an alimentary tract of the most distal 200 cm of ileum, which is anastomosed to the stomach.
The biliopancreatic limb is anastomosed to the alimentary tract either 75 or 100 cm proximal to the ileocecal valve, depending on the protein content of the patient’s diet.
Usually a prophylactic cholecystectomy is performed 2° to ↑ gallstone formation
89
BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH
Duodenal Switch differs from the BPD only in the proximal gut portion of the operation.
Resection of all the stomach, except for a narrow lesser curvature tube of the stomach is performed.
The duodenum is divided in its first portion, leaving an approximately 2-cm length of duodenum intact beyond the pylorus.
This end of the duodenum is then anastomosed to the distal 250 cm of ileum.
90
LAPAROSCOPIC ADJUSTABLE BAND
An inflatable silicone band is placed around the proximal stomach, & locked into its ring configuration via a self-locking system.
The band is attached to a reservoir system that allows adjustment of the tightness of the band.
This reservoir system is accessed through a subcutaneously placed port.
The band is then periodically adjusted, based on weight loss
91
When to consider Bariatric/Metabolic Surgery for Adolescents
Consider only after failure of > 6-12 months of intensive lifestyle modification with or without pharmacotherapy in adolescents with:
- BMI > 50 kg/m2 with mild comorbidities
- BMI ≥ 40 kg/m2 & significant, severe comorbidities
- BMI ≥ 35 kg/m2 if associated with DM II
- BMI ≥ 99th percentile for age
92
Contraindications for Bariatric/Metabolic Surgery for Adolescents
Medically treatable obesity, poorly controlled substance abuse, pregnancy, current eating disorder, or inability to adhere to postoperative recommendations/lifestyle changes.
93
Bariatric/Metabolic Surgery for Adults – Current Guidelines
BMI ≥ 40 kg/m2 (Class 3 obesity) without coexisting medical problems & without excessive surgical risk
BMI ≥ 35 kg/m2 (Class 2 obesity) & ≥ 1 severe obesity-related comorbidities, for weight control & improved CVD risk
BMI ≥ 30 kg/m2 (Class 1 obesity) & ≥ 1 of severe obesity-related comorbidities, for weight control & improved CVD risk
BMI ≥ 30 kg/m2 (Class 1 obesity) & DM II, for glycemic control & improved CVD risk
