WEEK 11 Flashcards
Describe the trend in obesity rates
Rates are rising dramatically, both in M+F and in different countries (especially the UK and US), also occurring in children which links into adult obesity
What are the two processes behind obesity pathogenesis?
1) Sustained positive energy balance (energy intake>energy expenditure)
2) Resetting body weight “set point” at an increased value (increase in hunger hormone, decrease in satiety hormone)
What societal changes can be made to combat obesity?
Food environment (portion distortion-increasing calories in food)
Physical activity environment
Addressing stigma
What individual treatment can be done to combat obesity?
Lifestyle and behavioural
Drugs
Surgery (bariatric)
What are the strengths of BMI in assessing obesity?
Cheap and cheerful Quick No special equipment required In people's homes Very useful at a population level
What is the weakness of BMI in assessing obesity?
Doesn’t account for muscle mass and fat mass differentiation
How is body fat distribution an independent determinant of health?
Waist fat mass (circumference) correlates with health issues (eg. MI), whereas hip fat mass (circumference) negatively correlates with health issues
LOOK AT THE DIFFERING METABOLIC SYNDROME DEFITIONS IN THE TABLE IN NOTES
WHO (insulin resistance plus two other factors)/ATP III (three factors)/IDF (central obesity plus two other factors)
Is the metabolic syndrome a benign disease?
No, patients with it have increased prevalence of all-cause and CV mortality, and CHD, MI and stroke
What does central adiposity correlate to?
Insulin resistance, therefore obesity correlates with relative risk of T2 diabetes
Detail the process of adipose tissue formation
Pluripotent stem cell-(recruitment)->Preadipocyte-(proliferation)->Multiple preadipocytes-(differentiation)->Adipocytes-(lipid accumulation)->Adipose tissue
What is the role insulin plays in adipose tissue mass regulation?
Insulin stimulates proliferation of preadipocytes into multiple preadipocytes and differentiation of multiple preadipocytes into adipocytes
What is the main route of management of obesity?
Weight loss (5-10% weight loss=reduction in T2 diabetes risk, reduction in CV mortality, improved BP and improvements to sleep apnoea)
LOOK AT THE NICE GUIDELINES FOR MANAGEMENT OF OBESITY WITH RESPECT TO BMI CLASSIFICATION
Changes include lifestyle change, diet and physical activity, drugs and surgery
What is the general principle of weight management?
Don’t choose weight loss intervention, patient chooses between offered treatments with help of the MDT
What is necessary when considering weight management?
Knowing your patient, their wishes and needs and avoiding obesity stigma (don’t be judgemental-lots of factors involved)
What are the factors to consider when choosing between treatment options for obesity?
Why? and why now?
Treatment targets (realistic)
Disease severity
Patient needs: how quickly? how much? (rapid vs. slow weight loss)
Causes of obesity/excess weight
Previous unsuccessful treatments
Evidence base for long term weight management
LOOK AT TABLE WITH DIFFERENT CAUSES OF OBESITY
(mono-)genetic or syndromic hypothalamic endocrine medication mental disorders lifestyle
Detail the 4M approach to understanding barriers to achieving patients aims?
Mental (eg. knowledge, expectations, self-image, anxiety etc)
Mechanical (eg. pain, obstructive sleep apnoea, oesophageal reflux etc)
Metabolic (eg. T2 diabetes, hypertension, cancer, infertility etc)
Monetary (eg. education, employment, disability, surgery etc)
What should you do when considering expected treatment outcomes?
Align treatment outcomes with the patient’s outcomes and work with the patient to develop realistic aims/expectations
What are the three principles of addressing clinical inertia and understanding previous success and failures?
1) escalate treatment dependent on response
2) don’t expose the patient to repeated cycles of ineffective treatment
3) don’t setup the patient for failure
What is disease staging?
A clinically based measure of severity that uses objective medical criteria to assess the stage of disease progression
What is the principle of disease staging for weight management?
Weight management shouldn’t be weight centric
Give two disease staging methods
1) Edmonton Obesity Staging System (EOSS)-stages 0 to 4
2) King’s criteria-stages 0 to 3
What three factors are involved in the EOSS?
1) Medical
2) Mental
3) Functional
Give five of the many factors that make up the King’s criteria
1) BMI
2) CV
3) Diabetes
4) Economic
5) Gonadal
What is the link between exercise and activity and obesity?
CV fitness prevents metabolic syndrome development
What are the NICE guidelines on physical activity for preventing obesity?
45-60 minutes of moderate-intensity activity per day
What are the NICE guidelines on physical activity for avoiding weight gain?
60-90 minutes of activity per day
What are some recommended types of physical activity?
Brisk walking, supervised exercise programmes, swimming, walking certain no. of steps per day
What is the main aim for physical activity encouragement?
Spending less time inactive
What is the main requirement for dietary interventions for obesity?
total energy intake
What is the recommended dietary intervention for sustainable weight loss?
600kcal/day deficit or low-fat diet
What are dietary interventions combined with?
Expert support and intensive follow-up
What are low-calorie diets (800-1600kcal/day) less likely to be?
Nutritionally complete
Give the three options for pharmacological weight management
Ortistat-energy wastage
Naltrexone/Bupropion-appetite suppression
Liraglutide 3.0mg-appetite suppression
What are the indications of Ortistat?
Adjunct to diet for obesity
What are the indications of Naltrexone/bupropion and Liraglutide 3.0mg?
adjunct to diet and physical activity for chronic weight management in:
a) obesity BMI
b) overweight BMI with comorbidity
What is shown by pharmacological intervention for weight management?
Clinically relevant weight loss achieved with lifestyle modification and continuing medication prevents weight regain
Give the four types of bariatric surgery
1) Adjustable gastric band (inflatable band used to create a small pouch, limiting food consumption)
2) Vertical sleeve gastrectomy (permanently removes most of stomach, leaving sleeve-shaped pouch-decreasing ghrelin (hunger hormone))
3) Roux-en-Y gastric bypass (creates smaller stomach and bypasses part of intestine; increased GLP-1 (satiety hormone))
4) Biliopancreatic diversion (similar to Roux-en-Y, variant called a duodenal switch retains the pyloric valve)
What is shown by surgical intervention for weight management?
Greater excess weight loss (especially long term) and greater diabetes retention rates/remission compared to standard care
What factors are involved at choosing the intervention?
Patient preference, cost, side effects profile, contraindications, aim of treatment, presence of CVD or T2 diabetes, presence of MH disorder
