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
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.
Procedure chart
Weight loss devices chart
Health at every size principles
Weight inclusivity
Health enhancement
Eating for well-being
Respectful care
Life-enhancing movement
Definitions
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)
