Week 9 Obesity in Primary Care Flashcards
Obesity
Definition
Defined as excess body fat leading to a health consequence
Chronic, relapsing, multi-factorial, neurobehavioral disease
Waist circumference measurement: key things when measuring and what does it measure?
- A “loose” way to measure one’s visceral fat
- Always measure consistently (same spot)
- Measure at end of normal expiration
- Should be used in addition to BMI to evaluate obesity associated CVD risk
Patients w/ BMI 25 – 35 kg/m2 to determine increased cardiometabolic disease risk - Normal values
- Men < 40 “ (102cm)
- Women < 35” (88cm)
Energy intake
What is it based on?
Ingestion of food (nutrients)
Homeostatic controls (hormones)
- Leptin increases satiety
- Ghrelin (stomach) increases hunger
- Insulin (pancreas) secreted when stomach senses food
- Leptin + insulin secreted in proportion to body fat - can be resistant to both
Hedonic control
- I.e: eating impulsively, eating in front of TV, eating when stressed, eating more when tired - make altered decisions
Energy expenditure
What is it based off of?
Thermogenic effect of Energy intake
Physical Activity
Basal Metabolic Rate
Basal metabolic rate
R/t amount of mm you have
- more mm = higher rate
Resting metabolic rate
Based off of total body mass
WHO “Obesity is the (insert) .”
…largest global chronic health problem.”
Recommended rate of weight loss
1-2lbs/week
Based on deficit of 500kcal - 1000kcal/day
Is there an ideal body weight?
NO
But we want BMI 20-22 according to literature
Cardiac benefits of reducing weight in obese patients
- Reduction in progression of T2DM by < 50%
- Improvements in HgbA1c with as little as 2% weight loss
- Decreased SBP and DBP
- Decreased total cholesterol, decreased LDL, increased HDL & decreased TG
Other benefits of losing weight
- Biomechanical complications reduced?
- Increased life expectancy
- Sleep apnea
- Depression
- Mobility
- Possible decrease in cancer risk
- Improvements in LBP, GERD, lower extremity arthralgia
- Possible decrease in drugs to treat complications in setting of obesity
Table of guidelines for providing obesity tx (nonpharm and pharm) dependent on BMI measurement
What is the most important contributing factor to initial and sustained weight loss?
Adherence
Benefits of exercise in context of obesity
- Slows cognitive decline
- Reduces bone loss
- Enhances sleep
- Improves quality of life
- Decreases r/f HTN, glucose intolerance, IR, dyslipidemia, inflammation and obesity.
Image of exercise benefits
When should dieting and physical activity should be attempted PRIOR to initiation of pharmacotherapy?
6 months
Dieting and exercise comprehensive program intails of…
- Reduced-calorie diet (-500kcal/day)
- Increase physical activity (~ 150min/wk; more for maintenance)
- Behavior Therapy (some structured behavior change with monitoring) – comprehensive lifestyle management
- These need to be long-term in order for their weight loss to be maintained long term
List of medications approved for weight loss
What BMI/#of complications do they have to be at to use these?
- Orlistat (Xenical, Alli)
- Phentermine HCL (Adipex)
- Phentermine/Topiramate ER (Qsymia)
- Buproprion/Naltrexone (Contrave)
- Liraglutide (Saxenda)
- Semiglutide (Wegovy)
BMI of 30kg/m2 or 27 with 1+ weight related complication
When to discontinue weight loss meds?
- Should be discontinued in 12-16wks if pt unable to achieve minimum of 5% weight loss
Weight loss meds chart
No phentermine if they’re on less than 2 anti-HTN med (but BP has to be controlled)
No phentermine/topiramate in pts w/ kidney stones – makes ppl tired – dose it at night
Bupropion SR/Naltrexone – doesn’t work
Metformin – off-label use for weight loss, used for PCOS, preDM, and weight gain 2/2 psychotropic medications.
Orlistat – FDA approved 12 years and above. Be careful in the elderly or those with neurogenic bladder or chronic neurological disease that may affect bowel movements (ie. MS, Spinal cord injuries, and Parkinson’s disease. Be aware of fat-soluble vitamin levels. Anyone at risk of deficiency may not be the best candidate for orlistat.
Phentermine – FDA approved for short-term use (3 months) 16 years and above. Be aware of the contraindications.
Phentermine + Topiramate – FDA approved 12 years and above. Avoid use w/o a history of kidney stones, depending on how remote the history is. Topiramate, “aka dopamax” can be sedating think safety and QOL. Be aware of contraindications. Topiramate is also teratogenic in the first trimester. Avoid using even if pt wants to lose weight prior to conception.
Liraglutide – FDA approved 12 years and above.
Semaglutide – FDA approved 12 years and above.
The Greater the BMI, consider medications FDA approved for long-term treatment (anything other than phentermine). Be aware of comorbidities; this is what is going to dictate the medications you choose.
When are devices and surgery needed in the context of obesity?
For those who have failed lifestyle modification, have weight related comorbidities, surgery and or devices may be the best option for those with Class III Obesity
Who does bariatric surgery benefit the most?
More effective for those with BMI > 40kg/m2 for long term weight loss
Guidelines for bariatric surgery
- BMI 40kg/m2 or greater
- BMI 35 - 39.9kg/m2 + T2DM, Heart Dz, OSA
- BMI 30 - 34.9kg/m2 + T2DM, Heart Dz, OSA (gastric band only)
Gastric bypass and Sleeve most common!
Procedure chart
Weight loss devices chart
Fill in the blank
Clinicians offer or refer adults with a (insert) to intensive, multicomponent behavioral interventions
BMI of 30 kg/m2 or higher
ACA, Medicare, and Medicaid/CHIP obesity services covered
- Affordable Care Act (ACA) 2010
- Obesity-related services = preventive services
- Medicare Part B
- Screening and behavioral counseling services for ≥ 30kg/m2
- Some bariatric surgery (RYGB, LSG)
- Medicaid & CHIP
- Coverage varies by state
- Obesity screenings, Weight loss medications, Bariatric surgery, Nutrition counseling
Timeline of intensive behavioral therapy for treatment of obesity
- Month 1: Face-to-face, once weekly
- Month 2-6: Face-to-face, once every other week
- Requirement: Documented 3kg weight loss
- If not achieved re-assess for 6 months
- Month 7-12: Face-to-face, once monthly
- Reassess readiness to change and BMI
Intensive behavioral therapy for treatment of obesity
- Screening for obesity in adults using measurement of BMI - doesn’t account for composition (not use in kids, or sarcopenia)
- Dietary (nutritional) assessment; and
- Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high intensity interventions on diet and exercise
Health at every size principles
Weight inclusivity
Health enhancement
Eating for well-being
Respectful care
Life-enhancing movement
Definitions
5 As framework
(ADA)
- Ask permission to address weight
- Assess the patient’s desired weight loss goal and reasons for wanting to lose weight
- Advise about treatments that match the patient’s goals and are likely to produce desired results.
- Agree on weight loss, lifestyle, and behavioral goals
- Assist the patient by creating a plan
Prochaska’s Stages of Change
- Pre-Contemplation: No intention of changing behavior in the foreseeable future. Pt will tend to be unaware that they have a problem & are resistant to efforts to modify the behavior. May be aware they have a “health issue” or that their practitioner is “worried”, but they may think there is nothing wrong.
- Contemplation: Aware they have a problem and are seriously thinking about changing, but have not yet made a commitment to taking action in the near future.
- Preparation: The stage of decision making. A commitment is made to take action w/i the next 30days and are already making small behavioral changes. “I already went out and did all the grocery shopping; or I’ve already talked to my boss about changing my schedule at work.”
- Action: Notable effort to change are made on a daily basis and they have now modified the target behavior to an acceptable criteria.
Maintenance: Work is done to stabilize their behavior change and avoid relapse, sustaining their actions for at least 6mos. With weight loss, maybe closer to 1-2yrs.
Key things for Promoting Healthy Behaviors
Motivational Interviewing
- Constructive and reflective communication used to help reduce health risk and change behavior
- Goal: identify difference between a pt’s current behaviors and his/her desired goals.
- Understand ambivalence and ‘resistance’ (“non-compliance”) is part of the process; and that it is different from lack of motivation.
- “OARS” = open-ended questions, affirmations, reflections, summarization
- Offers advise and helps create a plan not direct
Patient education for weight management
- Encourage/support diet, exercise and behavior modification
- Utilize approved weight loss medications for long-term weight maintenance, through the amelioration of obesity complications and amplify adherence to behavior change.
- Discussing and referring to bariatric surgery
- Guidelines based on obesity complications and efficacy
Weight history HPI components
- Highest adult weight? Lowest adult weight? Goal (weight)?
- Preoperative weight? Discharge weight? Nadir weight? Goal weight?
- Weight loss attempts in the past? Successes? How much lost? How?
- Relapsed and weight gain? What was the trigger/barrier?
- Medications, Devices &/or Bariatric Surgery: Have they had? Considered? Are they interested?
- H/o eating disorder?
- Ask about their “Typical day” of food and liquid intake
- Exercise, Sleep, stress management
Nadir weight
lowest weight achieved after surgery
Weight related history components
Current Health Status—Smoking history? Drug use? Immunization? Age-appropriate screenings
AFAB w/bariatric surgery – higher risk of developing osteopenia or osteoporosis
PMHx/PSHx—Weight related complications. Are there contraindications to the usage of medications, devices, surgery?
Are there contraindications to the weight loss process at all?
Are there other causes of weight gain?
FamilyHx—Give an insight to possible genetic factors for obesity, risk for complications, surgical support
PsychoSocialHx—Social issues, mental health history, eating disorder history, SDOH (education, employment, housing, supplemental income, food insecurity)
Some with low health literacy may not know about “portion sizing”
Medication history of weight gain
Not a comprehensive list
Things to look for in ROS
Vitamin B deficiency – Look for nystagmus = Wernicke’s encephalopathy
Check B1 – if normal –> alcoholism
Bariatric surgery – neuro exam
Want patients to move – resp and MSK – see if they have any weakness
Dumping syndrome post gastric bypass: glucose gets absorbed quicker – diarrhea, sweat (feel sick) (educate about timing and types of trigger foods)
GERD – reflux syndromes with gastric sleeve
Obesity classes
EOSS Obesity staging based on?
Complications
Obesity Objective findings
Look for complications if they didn’t have bariatric surgery
Stretch marks/striae - flesh tone instead of purple (cushing’s)
Obesity lab/diagnostics
R/o thyroid always – rare that it’s hypothyroid cause of obesity (lose 10lbs if tx hypothyroidism)
Role of PCNP in weight management
- Acknowledge obesity as a multifactorial chronic disease
- Communicate the health complications a/w overweight & obesity.
- Use a weight-centric approach to managing obesity related complications
- Prescribe medications for weight loss and adjust during the weight loss process.
- Be a guiding light for your pts and help them achieve meaningful weight loss
