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Endocrinology Exam 2 > Obesity as Chronic Disease > Flashcards

Obesity as Chronic Disease Flashcards

1
Q

Obesity = impaired _____

A

function

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2
Q

There are > ___ comorbid conditions &
affects quality & quantity of life that can be associated with obesity

A

160

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3
Q

Obesity in adolescents has increased from ↑ 5% to 17% in what timeframe?

A

the last 25 years

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4
Q

Obesity % in Developed vs. Developing countries

A

~23% in developed vs. ~13% in developing

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5
Q

T/F Obesity is higher with cesarean sections and bottle feedings vs. breast feeding

A

T

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6
Q

___% of obese children will become obese adults

A

80

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7
Q

What is the cause of obesity?

A

Combination of socioeconomic, genetic, & biologic factors
↑ Calories, ↓ Activity, & Genetic/Metabolic predisposition

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8
Q

T/F Inheritance of obesity is usually Mendelian

A

F

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9
Q

“obesity gene”

A

ob gene

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10
Q

Leptin

A

(Greek leptos, “thin”) is one of several appetite-suppression hormones

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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)

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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
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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

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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

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15
Q

Obese individuals often have a form of functional “___”

A

Leptin resistance

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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

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17
Q

The Four Horsemen of the Diabesaclypse

A

Soda
Frozen dairy
Pastries
Fast food

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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

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19
Q

Obese individuals have ____% of the risk of developing T2D

A

60

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20
Q

Obese indidividuals have >___% of hypertension and coronary heart disease risk

A

20

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21
Q

There are >____ complications that can occur from obesity

A

200

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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

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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”

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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
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25
Q

The USPSTF recommends that clinicians offer or refer adults with a body mass index (BMI) of 30 or higher to _____

A

intensive, multicomponent behavioral interventions

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26
Q

Rx for ↓television/screen time recommending

A

SWAP ENJOYABLE ACTIVITY FOR SEDENTARY TIME

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27
Q

TREATMENT & PREVENTION STRATEGIES that address the family as well, not just the child

A

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

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28
Q

What is healthy eating?

A

Nutrient rich, calorie poor

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29
Q

ORLISTAT MOA

A

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%

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30
Q

Orlistat Indication

A

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

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31
Q

Finer et al Trial Highlights for Orlistat

A

12 months, 228 participants
120 mg TID
≧ 5% weight loss (35 v 21%-placebo)
≧ 10% weight loss (28 v 17%-placebo)

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32
Q

XENDOS Trial Highlights for Orlistat

A

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

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33
Q

ORLISTAT Contraindications

A

Cholestasis
Chronic malabsorption syndrome
Hypersensitivity to orlistat
contraindicated during pregnancy; safety in lactation unknown

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34
Q

Side effects of Orlistat

A

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

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35
Q

Pearls for taking cyclosporine or levothyroxine with Orlistat

A

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.

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36
Q

NALTREXONE/BUPROPION (CONTRAVE) MOA

A
  • 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)
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37
Q

COR (Contrave Obesity Research) I Trial Highlights

A

≧ 10% weight loss (21% v 7%-placebo)

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38
Q

COR II (Contrave Obesity Research) Trial Highlights

A

≧ 10% weight loss (28% v 6%-placebo)

39
Q

COR-BMOD Highlights (Contrave + Behavioral modification)

A

≧ 10% weight loss (35% v 21%-placebo)

40
Q

COR-Diabetes highlights

A

≧ 10% weight loss (15% v 5%-placebo)

41
Q

NALTREXONE/BUPROPION (CONTRAVE®)
contraindications

A
  • 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
Q

Side effects of NALTREXONE/BUPROPION (CONTRAVE®)

A

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
Q

Adverse effects of NALTREXONE/BUPROPION (CONTRAVE®)

A

HTN (3.2% )
↑ HR
MI (<2% )
Hypoglycemia
Cholecystitis (2%)
Hematochezia (<2%)
Intervertebral disc prolapse (<2%)
Amnesia (<2%)
Angle Closure Glaucoma
Pneumonia (<2%)

44
Q

NALTREXONE/BUPROPION (CONTRAVE®)
Follow up/monitoring

A

↓ 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
Q

NALTREXONE/BUPROPION (CONTRAVE®)
PEARLS

A

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
Q

Black Box Warning of Naltrexone/Bupropion

A

increase or emergence of suicidal ideation, depression, mania, hypomania, or atypical thinking & behavior

47
Q

PHENTERMINE/TOPIRAMATE XR COMBINATION (QSYMIA®) MOA

A

↑ 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
Q

PHENTERMINE/TOPIRAMATE XR COMBINATION (QSYMIA®)
EQUIP Trial Highlights

A

≧ 10% weight loss
3.75/23 mg (18.8 v 7.4%-placebo)
15/92 mg (47.2 v 7.4%-placebo)

49
Q

PHENTERMINE/TOPIRAMATE XR COMBINATION (QSYMIA®)
CONQUER Trial Highlights

A

≧ 10% weight loss
3.75/23 mg (37.3 v 7.4%-placebo)
15/92 mg (47.6 v 7.4%-placebo)

50
Q

PHENTERMINE/TOPIRAMATE XR COMBINATION (QSYMIA®) contraindications

A

Use with MAOIs or within 14 days of discontinuation of MAOI
glaucoma
hypersensitivity or idiosyncrasies to sympathomimetic amines
hyperthyroidism
pregnancy

51
Q

PHENTERMINE/TOPIRAMATE XR COMBINATION (QSYMIA®) adverse effects

A

Seizure, angle-closure glaucoma
Acute myopia
Suicidal behavior (0.43%)
Hypohidrosis

52
Q

PHENTERMINE/TOPIRAMATE XR COMBINATION (QSYMIA®) common adverse effects

A

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
Q

Is PHENTERMINE/TOPIRAMATE XR COMBINATION (QSYMIA®) safe in pregnancy?

A

Contraindicated during pregnancy
Individuals of Reproductive Potential
(-) pregnancy test before starting, then q month
♁ pts: use effective contraception during treatment

54
Q

PHENTERMINE/TOPIRAMATE XR COMBINATION (QSYMIA®) PEARLS

A

May ↓ visual acuity &/or cognition. Avoid activities requiring clear vision, mental alertness, or coordination until drug effects are realized.
May impair heat regulation.

55
Q

LORCASERIN (BELVIQ®)

A

FDA Approval Rescinded 2/23/2020
Post marketing trial showed increased rates of lung & pancreatic cancer

56
Q

TIRZEPATIDE (MOUNJARO®) MOA

A

Dual glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor agonist
“Twin-cretin”

57
Q

TIRZEPATIDE (MOUNJARO®) GIP and GLP-1RA mechanisms

A

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
Q

Contraindications of Mounjaro

A

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
Q

TIRZEPATIDE (MOUNJARO®) Serious adverse effects

A
  • 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
Q

Is TIRZEPATIDE (MOUNJARO®) safe in pregnancy?

A

Contraindicated during pregnancy

61
Q

PEARLS of TIRZEPATIDE (MOUNJARO®

A

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
Q

SEMAGLUTIDE (WEGOVY®) MOA

A

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
Q

SEMAGLUTIDE (WEGOVY®) contraindications

A
  • hypersensitivity to drug/class/component
    pregnancy
  • medullary thyroid CA or family hx
  • multiple endocrine neoplasia syndrome type 2
  • suicidality hx
  • suicidal ideation
64
Q

SEMAGLUTIDE (WEGOVY®) serious adverse effects

A

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
Q

SEMAGLUTIDE (WEGOVY®) Common adverse effects

A

Nausea (44%)
Diarrhea (30%)
Vomiting (24%)
Constipation (24%)
Abdominal pain (20%)
Headache (14%)
Fatigue (11%)

66
Q

Is SEMAGLUTIDE (WEGOVY®) safe in pregnancy?

A

Contraindicated during pregnancy
Possibly unsafe in lactation

67
Q

SEMAGLUTIDE (WEGOVY®) PEARLS

A

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
Q

After 68 weeks, semaglutide cut the calculated risk for possible future development of type 2 diabetes in study participants by > ___%

A

50

69
Q

LIRAGLUTIDE (SAXENDA®) MOA

A

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
Q

LIRAGLUTIDE (SAXENDA®) contraindications

A

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
Q

LIRAGLUTIDE (SAXENDA®) Serious adverse effects

A

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
Q

LIRAGLUTIDE (SAXENDA®) common adverse effects

A

Hypoglycemia
monotherapy, 9.7 - 23%
combo therapy, 3.60-43.6%

Nausea (39.3% )

73
Q

Is LIRAGLUTIDE (SAXENDA®) safe in pregnancy?

A

No

74
Q

LIRAGLUTIDE (SAXENDA®) Pearls

A

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
Q

STIMULANT AGENTS MOA

A

Similar pharmacologic activity to amphetamines
Weight loss mechanism of action unknown
Stimulates the CNS → ↓ appetite & ↑ blood pressure

76
Q

STIMULANT AGENTS Indication

A

Indicated for short-term weight loss only

77
Q

STIMULANT AGENTS contraindications

A

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
Q

STIMULANT AGENTS Serious Adverse effects

A

Cardiomyopathy
Heart valve disorder
Heat stroke
Cerebral hemorrhage
Cerebral ischemia
Psychotic disorder
Primary pulmonary hypertension
Myocardial ischemia
Rhabdomyolysis

79
Q

STIMULANT AGENTS Common Adverse effects

A

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
Q

Are STIMULANT AGENTS safe in pregnancy?

A

No

81
Q

STIMULANT AGENTS PEARLS

A

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
Q

Weight loss medication may be considered in adolescents if:

A
  • 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
Q

SURGICAL OPTIONS for Obesity

A

Bariatric surgery for obesity
25-33% total weight loss
Maintained long-term
Only 1% of US patients receive the procedure

84
Q

LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS

A

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
Q

Bariatric Outcomes Longitudinal data

A

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
Q

STAMPEDE Trial (Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently) data

A

80% of DM II patients maintained HbA1c <7%
Pts without DM were ~92% less likely to develop DMII compared to non-surgical pts

87
Q

SLEEVE GASTRECTOMY

A
  • 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
Q

BILIOPANCREATIC DIVERSION Procedure

A

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
Q

BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH

A

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
Q

LAPAROSCOPIC ADJUSTABLE BAND

A

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
Q

When to consider Bariatric/Metabolic Surgery for Adolescents

A

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
Q

Contraindications for Bariatric/Metabolic Surgery for Adolescents

A

Medically treatable obesity, poorly controlled substance abuse, pregnancy, current eating disorder, or inability to adhere to postoperative recommendations/lifestyle changes.

93
Q

Bariatric/Metabolic Surgery for Adults – Current Guidelines

A

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

Endocrinology Exam 2 (4 decks)

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