Case 16 - SIMPLE - 45 yo overweight

Question 1

Risks of obesity

Answer 1

• increase insulin resistance, increases LDL and Triglycerides, decreases HDL
• is a risk factor of HTN, T2Dm, CHD, stroke, PVD, CHF, A fib, gout, OA, back pain, GERD
• patients with BMI >40 have higher death rates from cancers including lymphoma, myeloma, and gi cancers

Question 2

Coronary heart disease risk assessment

Answer 2

Risk factors: tobacco, HTN, HDL <40, high LDL, fam hx of premature CHD, age
Risk equivalents: diabetes, symptomatic carotid artery disease, peripheral artery disease, AAA

Question 3

Dyslipidemia etiologies

Answer 3

• familial
• cauesd by diabetes, liver disease, neprotic syndrome, hypothyroidism, hepatitis, thiazide diuretics, beta blockers, oral estrogens

Question 4

Metabolic syndrome definition

Answer 4

Any three of the following:

• fasting glucose >100 mg/dl
• BP >130/85
• trigylcerides >150
• HDL < 40 for men 40 for men >35 for women)

Question 5

Pathophysiology of metabolic syndrome

Answer 5

• insulin resistance is underlying mechanism

Question 6

Complications of metabolic syndrome

Answer 6

CHD, diabetes, hepatic steatosis, hepatocellular carcinoma, cholangiocarcinoma, CKD, OSA, gout

Question 7

Treatment of metabolic syndrome

Answer 7

1st line- aggressive lifestyle management

- meds offered if lifestyle management not successful

Question 8

History for pt with metabolic syndrome

Answer 8

• dietary history
• weight history
• review of physical activity - determine caloric req.
• social history (tobacco, alcohol, other subs)
• psychosocial stress
• sleep history - snoring, arousal, daytime somnolence

Question 9

Physical exam for CHD

Answer 9

• increased waist circumference (>40 M, <35 F)

- increased waist to hip ratio

Question 10

Signs of hypercholesterolemia

Answer 10

• xanthelasma on eyelids

- xanthomas on extensor tendons

Question 11

Signs of vascular disease on exam

Answer 11

carotid bruit, diminished peripheral pulses, HTN, increased abdominal aortic size

Question 12

Signs of Cushing’s syndrome/cortisol excess

Answer 12

striae, hyperpigmentation, moon facies, buffalo hump, easy bruising, muscle weakness

Question 13

Signs of hypothyroidism

Answer 13

fatigue, cold intolerance, constipation, depressed tendon reflexes

Question 14

Calculating basal metabolic rate

Answer 14

Multiply body weight times 10 and multiply that number by an activity factor:

• 1.3 if sedentary
• 1.5 for moderate activity
• 1.7 for heavy activity
• 1.9 for intense activity
• to lose weight, caloric intake < BMR + additional activities

Question 15

Behavioral counseling, 5 As

Answer 15

Assess dietary practices
Advise patient to change dietary practices
Agree with patient on goals
Assist in changing dietary practices
Arrange follow-up

Question 16

Studies for metabolic syndrome

Answer 16

• fasting lipid profile, LDL= TC - (HDL+TG/5)
• National cholesterol education program screening recommendations: all adults over 20, fasting lipids every 5 years
• USPTF recommends screening in men >35, women >45 and younger adults with CHD risk factors

Question 17

Diabetes screening cutoffs

Answer 17

• fasting glucose of >126 or random glucose >200 indicates diabetes
• fasting glucose 100-125 indicates pre-diabetes
• hemoglobin A1C 5.7-6.4% is prediabetes
• HbA1C >6.5 is diagnostic of diabetes

Question 18

Management of LDL dyslipidemia

Answer 18

• therapeutic lifestyle changes
• low fat, low cholesterol diet
• increased physical activity
• medications: statins, bile acid sequestrants, nicotinic acid (niacin), fibric acid, ezetimibe (prevents cholesterol absorption)
• check lipids 6 weeks after initiating therapy, and then every 6-12 months afterwards

Question 19

Statin side effects

Answer 19

Hepatic dysfunction and myopathy

Question 20

HDL dyslipidemia treatment

Answer 20

• lifestyle interventions

Question 21

Medication for weight loss

Answer 21

• orlistat - gi lipase inhibitor - decreases fat absorption - only medication approved by FDA for long term treatment of obesity
• phentermine - modest weight loss but stimulant effects
• OTC weight loss supplements - not regulated by FDA