K1N334 Midterm2 Flashcards
1
Q
What is the prevalence of obesity and overweight in Canada? %?
A
obesity ~20% and OW ~34%
2
Q
What are the 5 changes (steps) since 2007 when looking at obesity?
A
- Declaration of obesity as a chronic disease (CMA, 2015)
- Impact of bias, stigma, and discrimination
- Advances in the Science of obesity and weight regulation
- Advances in Obesity Treatments & Therapies
- Recognition of patient-centered care and outcomes, beyond weight loss
3
Q
What 2 things can be used as screening tools for obesity?
A
BMI and waist circumference
4
Q
What is the new definition of obesity?
A
Obesity is defined as a prevalent, complex, progressive, and relapsing chronic disease characterized by abnormal or excessive body fat (adiposity) that impairs health.
5
Q
What should the diagnosis of obesity be based on?
A
The presence of functional, medical, and/or psychosocial impairments related to the presence of abnormal or excess body fat rather than on anthropometric measures alone.
6
Q
What was the old definition of obesity?
A
Defined by BMI, a measure of size, not health. Time to move away from a weight centric definition and focus on health.
7
Q
What is the Goal of the obesity guidelines?
A
To improve the standard of, and access to, care for individuals with obesity across Canada.
8
Q
What are the 2 key principles of obesity management?
A
- Obesity should be managed using evidence-based chronic disease management principles, must validate patients’ lived experiences, move beyond the simplistic approaches of “eat less, move more”, and address the root drivers of obesity.
- People who are living with obesity should have access to evidence-informed interventions, which should include medical nutrition therapy, physical activity, psychological interventions, pharmacotherapy, and surgery.
9
Q
What directly impacts the health and well-being as well as access to care of people with obesity?
A
bias and stigma
10
Q
What are 4 ways to recognize and address weight stigma?
A
- Health care providers should assess how their own beliefs and attitudes towards people with obesity influence health care delivery
- Health care providers should be aware that internalized weight bias (attitudes of people living with obesity towards themselves) can adversely affect behavioural and health outcomes
- Health care providers should avoid using judgmental words, images and practices when working with patients
- Health care providers should avoid assuming that an ailment or complaint a patient presents with is related to their body weight
11
Q
What is Step 1 in the Five-Step (5As) Approach to Obesity Management?
A
Step 1 (ASK): Recognition of obesity as a chronic disease by the health care providers, who should ask the patient permission to offer advice and help treat this disease in an unbiased manner.
12
Q
What is Step 2 in the Five-Step (5As) Approach to Obesity Management?
A
Step 2 (ASSESS): Assessment of an individual living with obesity using appropriate measurements, identifying the root causes, complications, and barriers to obesity treatment.
13
Q
What is Step 3 in the Five-Step (5As) Approach to Obesity Management?
A
Step 3 (ADVISE): Discussion of the core treatment options (medical nutrition therapy and physical activity) and adjunctive therapies that may be required, including psychological, pharmacological, and surgical interventions.
14
Q
What is Step 4 in the Five-Step (5As) Approach to Obesity Management?
A
Step 4 (AGREE): Agreement with the person living with obesity regarding goals of therapy, focusing mainly on the value that the person derives from health-based interventions.
15
Q
What is Step 5 in the Five-Step (5As) Approach to Obesity Management?
A
Step 5 (ASSIST): Engagement by health care providers with the individual with obesity in continued follow-up and reassessments, and encouragement of advocacy to improve care for this chronic disease.
16
Q
What are the 5 suggestions for step 2 (assessment) of the approach to obesity management?
A
- Healthcare providers involved in assessing people living with obesity use the 5As of Obesity Asking for their permission and assessing their readiness to initiate treatment.
- Healthcare providers can measure height, weight and calculate Body Mass Index (BMI) in all adults, and measure waist circumference in individuals with a BMI 25–35 kg/m2.
- Comprehensive history to identify root causes of weight gain as well as complications of obesity and identify potential barriers to treatment.
- We recommend blood pressure measurement in both arms, fasting glucose or glycated hemoglobin and lipid profile to determine cardiometabolic risk
- Consider using the Edmonton Obesity Staging System to determine the severity of obesity and to guide clinical decision making
17
Q
What are the 3 Pillars of Obesity Management that Support Nutrition and Activity and which step is this a part of?
A
Step 3.
1. Psychological Intervention (behaviour modification, manage sleep, time stress, cognitive behavioural therapy).
2. Pharmacological Therapy (liraglutide, naltrexone, orlistat)
3. Bariatric Surgery (sleeve gastrectomy, gastric bypass, biliopancreatic diversion)
18
Q
What is the criteria for Pharmacological Therapy?
A
BMI >= 30kg/m2 or BMI >= 28kg/m2 with obesity related complications
19
Q
What is the criteria for Bariatric Surgery?
A
BMI >= 40kg/m2 or
BMI >= 35-40kg/m2 with obesity related complications or
BMI >= 30kg/m2 with poorly controlled type 2 diabetes
20
Q
What are the 3 goals when defining success and what do they all require?
A
- Prevention (1 pound per year!)
- Losing weight
- Maintaining weight loss
All 3 goals require understanding of energy balance
21
Q
What is clinically significant weight loss and how do you get there?
A
> 5% of baseline body weight
Reduces CV disease and type 2 diabetes risk factors
How do you get there?
* Diet
* Exercise
* Medications
* Surgery
* A combination?
22
Q
How do you determine EE?
A
the total volume of physical activity
Volume = frequency x time
23
Q
What is FITT in exercise?
A
- Frequency
- Intensity
- Time
- Type
24
Q
Why would increasing EE for weight loss work?
A
- Effect on energy balance is proportional to increase in EE
- Increase fat and CHO oxidation would be expected to have favorable health consequences
25
Why wouldn't increasing EE for weight loss work?
Achievable amounts of exercise lead to small increases in EE
Adherence to changes in exercise/PA is poor
Increasing EE could be linked to compensatory increases in EI
26
Why would increasing energy intensity for weight loss work?
* Same energy expenditure in less time
* Greater improvements in fitness and other risk factors
* Greater preservation of FFM
* Decreased appetite after High Intensity exercise
* Variety/More enjoyable for some people
27
Why wouldn't increasing energy intensity for weight loss work?
* Less enjoyable
* Less accessible
* Greater risks/safety concerns
* Less self efficacy (belief in ability to perform such activities)
28
What are 2 types of energy intensities and how would each benefit weight loss?
1) Low intensity exercise
E.g., Intensity that maximizes fat oxidation?
(Lipoxmax; Fat(ox)max; Fatmax)
2) High intensity exercise
E.g., High intensity interval training (HIIT)?
EPOC?
29
At what intensity is the greatest absolute fat oxidation?
65%
30
At what intensity is the greatest relative fat oxidation?
25%
31
At what intensity is the greatest caloric expenditure, relative CHO oxidation and absolute CHO oxidation?
85%
32
What is the most important thing when trying to lose weight?
Adherence!
33
Why wouldn't resistance training work for weight loss?
* Effect on FFM is small
* Effect on FFM during energy restriction is even smaller.
* Therefore effect on RMR is likely not meaningful
* Energy cost of resistance training is small
34
Why would resistance training work for weight loss?
Resistance training will cause:
- increased free living PA
- increased fat oxidation
- increased muscle mass
- increased RMR
- increased TEE
- decreased body fat
35
What is important about resistance training for weight loss?
* Not very effective for weight loss alone
* BUT can contribute to change in body composition
* Can be important for certain populations (elderly, diabetes) due to other important effect
* Improved metabolism
* Maintenance of function
36
Why would exercise for Class II/III obesity work?
* Can contribute to negative energy balance
* Can improve health
* Can improve quality of life
* Improve response to bariatric surgery
37
Why wouldn't exercise for Class II/III obesity work?
* Fitness too low to achieve meaningful energy expenditure
* Too many co-morbidities that could be worsened by exercise (e.g., joint pain…)
* Time for exercise and fatigue from exercise could interfere with other activities
38
What are things to consider for Exercise for Class II/III obesity?
Access to your facility
Access to your equipment
Adapted exercises
Adapted places to sit, and changing facilities
39
What is the 1st guideline in the Canadian Obesity Guidelines?
1. Aerobic physical activity (30-60 minutes of moderate to vigorous intensity most days of the week) can be considered for adults who want to:
⮚ Achieve small amounts of body weight and fat loss;
⮚ Achieve reductions in abdominal visceral fat and ectopic fat such as liver and heart fat, even in the absence of weight loss;
⮚ Favour weight maintenance after weight loss
⮚ Favour the maintenance of fat-free mass during weight loss;
⮚ Increase cardiorespiratory fitness and mobility
40
What is the 2nd guideline in the Canadian Obesity Guidelines?
2. For adults living with overweight or obesity, resistance training may promote weight maintenance or modest increases in muscle mass or fat-free mass and mobility.
41
What is the 3rd guideline in the Canadian Obesity Guidelines?
3. Increasing exercise intensity, including high-intensity interval training, can achieve greater increases in cardiorespiratory fitness and reduce the amount of time required to achieve similar benefits as from moderate-intensity aerobic activity.
42
What is the 4th guideline in the Canadian Obesity Guidelines?
4. Regular physical activity can improve many cardiometabolic risk factors, including:
⮚ Hyperglycemia and insulin sensitivity
⮚ High blood pressure
⮚ Dyslipidemia
43
What is the 5th guideline in the Canadian Obesity Guidelines?
5. Regular physical activity can improve health-related quality of life, mood disorders (i.e., depression, anxiety) and body image in adults with overweight or obesity
44
What is the strongest predictor of
death?
Exercise capacity
Absolute fitness is better predictor
45
12% improvement in survival in METS?
1 MET
46
What is the risk of death if METS <5?
Twice
47
What other advantages of physical activity for participants looking to lose weight:
* Fitness
* Quality of life/Independence
* Improvements in risk factors (glucose, BP)
* Fat distribution or quality?
* Prevention of weight regain
48
Why are the decisions to eat food complex?
– psychological & environmental
– initiation/termination of meals, size, composition, frequency
– lifestyle habits, drive to seek tasty foods, enjoyment, social
49
What is the Physiology of EI?
1) Afferent peripheral hormonal signaling
* Appetite (orexigenic)
* Satiety (anorexigenic)
2) Central integration
3) Efferent signaling
4) Behavioural change
50
What are 5 hormones that regulate energy intake and what part of the brain do they act on?
GHRELIN
PYY
PP
GLP-1
LEPTIN
Arcuate Nucleus “ARC Region” of the brain
51
What is the vagus nerve?
● Important source of indirect neuronal stimulation
● Composed of efferent/ afferent sensory fibers
● May be involved directly with CNS or indirectly with these peripheral peptides
52
What are 4 categories of exercise?
* Low-intensity continuous – <50% VO2max
* Moderate-intensity continuous – 50-70% VO2max
* High-intensity continuous – >70% VO2max
* Interval training
- HIIT – intervals up to maximal
*- SIT – intervals above maximal
53
What is the summary / results of recent EMRL work? (appetite regulation study)
* Novel human work
* Utilized exercise intensity and/or sodium bicarbonate supplementation to modulate endogenous lactate
* Data shows greater blood lactate accumulation is associated with greater suppression of ghrelin, appetite
* Investigations into potential other mechanisms involved (IL-6 & sex hormones) is ongoing
54
What is a "depot for energetic errors"?
Adipose tissue
55
What are the 7 steps of Medical Nutrition Therapy?
1. Nutrition recommendations to meet
individual values for long term adherence
2. Receive individualized medical nutrition therapy from a registered dietitian to manage problems
3. May receive medical nutrition therapy from a registered dietitian to reduce BW and circumference and improve glycemic control and blood pressure
4. Can consider any of multiple medical nutrition therapies to improve health-related outcomes choosing options that lead to long term adherence
5. Consider behavioural interventions that target a 5%–7% weight loss, to improve glycemic control, blood pressure and blood lipid targets, reduce type 2 diabetes
6. Intensive lifestyle interventions that target a 7%–15% weight loss
7. Nondieting approach to improve quality of life
56
What are 6 types of diets?
o Vegetarian diets
o Low fat diets
o Low Carbohydrate diets
o High Protein diets
o Very low Calorie diets
o Crash diets
57
What is a diet?
The sum of food and drink they habitually
consume
58
What is dieting?
The practice of attempting to achieve or maintain a certain weight through nutritional intake
59
What factors effect people's diet?
Ethical and religious beliefs, clinical need, $$ etc.
60
What is a vegetarian diet?
excludes meat and animal by-products (e.g., gelatin and rennet)
61
What is a fruitarian diet?
Raw fruit
62
What is a Lactovegetarian diet?
certain types of dairy but excludes eggs and rennet foods
63
What is a Lacto-ovo vegetarian diet?
includes eggs and dairy but no animal flesh
64
What is a Vegan diet?
Contains only plants and foods made from plants. It excludes any food derived from animals (e.g., eggs, dairy, honey)
65
What are 2 types of semi-vegetarian diets?
Flexitarian diet and Pescetarian diet
66
What are 4 types of vegetarian diets?
Fruitarian diet
Lactovegetarian
Lacto-ovo vegetarian
Vegan diet
67
What is a Flexitarian diet?
predominantly vegetarian diet but meat is occasionally consumed
68
What is a Pescetarian diet?
a diet which includes fish but not meat
69
What does the American Dietetic Association and Dieticians of Canada say about vegetarian diets?
Appropriately planned vegetarian diets can be healthful, nutritionally adequate, and provide health benefits in the prevention and treatment of certain diseases.
70
What are the advantages of a vegetarian diet?
* Lower level of saturated fats
* Lower consumption of added sugar
* Low or no consumption of cholesterol
* High intake of: (Fibre, Magnesium, Potassium, Folate, Antioxidants, Phytochemicals)
* On average have lower reported BMI
* Have a lower odds of mortality from heart disease (Lower BP, Lower cholesterol, Lower rates of hypertension, T2D, and certain cancers)
71
What are the disadvantages of a vegetarian diet?
* Limiting foods makes adequate consumption of nutrients more difficult
* Risk of vitamin B12 deficiency
* Inadequate vitamin D consumption if no dairy is consumed
* Hard to consume adequate amount of
calories
* High risk of iron deficiency anemia (increase absorption by consuming citrus juice)
* Risk of protein deficiencies (Plants lack certain amino acids)
72
What are low fat diets?
- Normally:
o <30% of EI from fat (some say 10-15%)
- May also include
o <10 EI from saturated fat?
o No trans fats?
o removed limit on cholesterol BUT emphasize eating less because those foods tend to be high in sat. fats.
o Can be “Ad libidum” or with concomitant emphasis on energy restriction.
o Epi studies show populations with lower fat intake have less obesity
73
Why would low fat diets work?
o ***Energy density (cheese vs. vegetables)
o Efficiency of storing fat as fat
o Low thermic effect of feeding of fat
o Taste/texture
o Fat has low Satiety?
74
Why wouldn't low fat diets work?
o Palatability
o High CHO/sugar content
o Evidence fat intake ↓ while obesity rates ↑
o Fat can have high satiety? Depends on:
- Amount of fat?
- Fatty acid chain length [medium chain are more satiating than long chain]
- Degree of Saturation [more saturated = more satiety]
- What it is eaten with (Fiber, CHO, Sugar)
75
What is the evidence of the low fat diets?
o Randomized, controlled trials (RCTs)
o Meta-analyses…
- For each 1% reduction in %fat intake there is approximately 1.6g/day of weight loss
- Low fat diet combined with energy restriction can lead to more weight loss than Low fat diet alone
76
Why are low fat diets preferred?
* for metabolic reasons, uncoupled fat intake and oxidation
* high fat foods or energy dense foods have weak satiety effects and promote overconsumption
* low fat diets are helpful for weight loss and may help with maintained weight loss may be associated with type of fat
* low fat diets good for heart health and certain cancers
77
What are the negative side effects of a low fat diet?
o Low palatibility – fat tastes good!
o Essential FA, lipo-soluble vitamins, HDL?
* Long-term adherence
78
What are low carb diets?
less than 20 g CHO/day for 2 weeks then <50g/day
ad libidum intake of fat and animal protein
No universal definition:
<100g
<30% CHO
20-30% Prot
50 %Fat
79
What is a Reduced carbohydrate diet?
>130 g of carbohydrate per day, up to 45% of total calories
80
What is a Low carbohydrate diet?
30-130 g of carbohydrate per day
81
What is a Very low-carbohydrate ketogenic(VLCK) diet?
<30g of carbs/day; will usually permit ketosis to occur
82
Why would low carb diets work?
- adipose tissue metabolism when CHO absent
- Ketones – produced when burning fat (ie.
Not enough CHO); interacts with incretine hormones (CCK/ghrelin) to suppress appetite.
- rapid weight loss due to:
* appetite suppression
* water loss (1-2kg in 7-14 days)
83
Do ketones suppress appetite?
Not directly, but there are associations with appetite
* Little doubt that ketogenic diets are associated with suppressed appetite.
* Evidence is less clear that it is the ketones that actually reduce appetite in these diets.
84
Why wouldn't low carb diets work?
- Too restrictive
- Unlikely to be adhered long-term
- Concerns with high meat consumption
- Discouraging after initial success slows down
- Potential for nutritional inadequacies?
- Potential interference with higher amounts of training?
85
What are the negative side effects of low carb diets?
o Less improvement in LDL-Chol (vs. low fat)?
o Increased calcium excretion; and homocysteine
o Low energy, bad breath
o Cancer???
86
What are high protein diets?
- Not as consistently defined and are often hard to distinguish from low carb diets
- Relative terms (>25% of kcal from protein)
- Relative terms (>1.2 g protein per kg of body weight)
87
Why would high protein diets work?
o High satiety
o Energy demanding to store excess protein
o Can taste good
o Preserve fat free mass
88
Why wouldn't high protein diets work?
o Concerns with high meat consumption
o Potentially costly
89
What is the evidence for a high protein diet?
High protein may be particularly helpful for prevention of weight regain.
o May be particularly interesting for prevention of loss of fat free mass
o Evidence is not consistent to date
* Effect on FFM is small
* May require resistance training
* FFM is not the same as muscle mass!
90
What are the risks of a high protein diet?
o Often similar to low carbohydrates
o Issues with some protein supplements (Excess protein is hard on the kidney’s, can contribute to dehydration etc.)
o Health issues with high meat consumption
- High temp cooking produces carcinogens
- Haem Iron (found in red meat is easy to absorb; non-haem is vegetable based proteins)
91
What is a Very Low Calorie Diet (VLCD)?
< 800 kcal… or <50% of RMR
- huge losses of lean tissue and minerals
92
Who are VLCD for?
o BMI > 30 kg/m2 at risk of diabetes/CVD
o No medical and behavioral contraindications
o Non pregnant
o People who have money (expensive)
93
Which type of diet do the Canadian guidelines NOT talk about?
VLCD
94
Why would Very Low Calorie Diet's work?
- “Simple” to follow
- No food preparation
- No calorie counting
- Large energy deficit
- Rapid weight loss can be motivating
- Starting point to other changes (exercise).
- Help break eating habits or “addictions”?
95
Why wouldn't a Very Low Calorie Diet work?
- Not a long-term solution
- No change in behavior. Once VLCD is done, people return to old behaviors.
- Very costly
- Must be medically supervised
- Safety
96
What are the negative side effects of a Very Low Calorie Diet?
- Gallstones (up to 25% of patients in some studies… risks can be ~/> of 7g of fat).
- Others: cold intolerance, hair loss, headache, fatigue, dizziness, volume depletion (with electrolyte abnormalities), muscle cramps, and constipation
- Deficiencies in vitamins and minerals
97
What are 4 diet plans which involve making
extreme, rapid changes to food consumption?
- Cabbage soup diet
- Grapefruit Diet
- Master Cleanse Diet
- Fat flush diet
98
What is the key difference when comparing diets?
Adherence!!
99
What are 3 types of surgery
■ Restrictive
■ Malabsorptive
■ Mixed procedures
100
What is the eligibility and availability of surgery for Obesity?
1 in 171 individuals with a BMI >35kg/m2
101
What is a summary of the Obesity Canada Report Card?
* Certified bariatric designation is growing
* No official guidelines or policies for obesity treatment and management
* Lack interdisciplinary teams in primary care
* Patients expected to cover costs of meal replacements within medically supervised programs ($1000-2000/month)
* Medications for obesity are not covered through public drug benefit programs
* Available to 1/171 adults w/ obesity per year
* Wait times up to 8 years
102
What is Bariatric surgery (weight-loss surgery)?
Refers to surgery performed in patients with a BMI of 40 kg/m2 or greater and those with a BMI between 35-40 kg/m2 and a major medical comorbidity in order to:
■ Support weight loss
■ Treat/prevent obesity-related comorbidities (e.g., diabetes, hypertension, cardiovascular disease, obstructive sleep apnea)
103
What is bariatric surgery eligibility?
■ a BMI > 40 kg/m2
- Strong desire for weight loss
- Understanding of the impact of surgery
■ A BMI between 35 – 40 kg/m2 with comorbidities that are known to improve with weight loss
- Severe sleep apnea
- Severe diabetes
- Physical problem interfering with lifestyle
104
What are the Contraindications of Bariatric Surgery?
■ >60 years of age
■ Medical conditions making surgery “high risk”
■ Pregnancy
■ Genetic conditions (e.g. Prader-Willi)
■ Certain mental health disorders (suicide attempts)
■ Substance abuse / alcohol abuse
■ Poor attendance + refusal to make lifestyle changes
■ Unable to comprehend advice
105
What happens at the initial clinic assessment at the Edmonton Adult Bariatric Specialty Clinic?
- Determine patient specific barriers to weight management
- Develop an individualized care plan (behaviour modification, counseling for nutrition, physical activity, and mental health, surgical treatment for obesity).
- Assess if bariatric surgery is an option
106
Do men or women more commonly get surgery?
Women
107
What is the most common type of surgery?
Gastric Bypass
108
What are Restrictive procedures?
■ Restricts the amount of food the stomach can hold
■ Does not interfere with normal digestion
■ Makes smaller pouches to hold food
109
What are Malabsorptive procedures?
■ Combines stomach restriction with a partial bypass of the small intestine
■ Reduces the amount of calories and nutrients the body absorbs
110
What are the advantages of Adjustable Gastric Banding (AGB)?
*restrictive
■ Simple and relatively safe
■ Very short recovery period
■ Major complication rate is low
■ No altering of the natural anatomy
111
What are the disadvantages of Adjustable Gastric Banding (AGB)?
*restrictive
■ >5% percent failure rate because of:
- Balloon leakage, band erosion/migration
- Deep infection
■ Slower initial weight loss
■ In some case weight loss may be less pronounced than other surgeries
■ Less improvement of diabetes than with bypass
112
What are the advantages of a Sleeve Gastrectomy?
*restrictive
■ No insertion of foreign objects
■ Reduces food intake (removes Ghrelin Cell mass: lower hunger)
■ No malabsorption of nutrient
■ Low potential for leakage
113
What are the disadvantages of a Sleeve Gastrectomy?
*restrictive
■ Irreversible
■ Inadequate weight loss/gain
■ Newer technique… more unknown. Stretch of sleeve?
■ Complications are rare but serious – if a leak occurs, takes months to resolve.
114
What is a Roux-en-Y Gastric Bypass?
*malabsorptive
■ A small pouch is created to
restrict food intake
■ A Y shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum and first portion of the jejunum
115
What are the advantages of a Roux-en-Y Gastric Bypass (RGB)?
*malabsorptive
■ Significant weight loss
■ Greatly controls food intake
■ Reversible in an emergency - this procedure should be thought of as permanent
■ Minimal diet restriction
116
What are the disadvantages of a Roux-en-Y Gastric Bypass (RGB)?
*malabsorptive
■ Staple line failure
■ Ulcers
■ Narrowing/blockage of the stoma
■ Vomiting if food is not properly chewed or eaten too quickly
■ Risk of deficiencies in vitamins (B12), iron and calcium
117
What is Dumping Syndrome?
Sugary food leaves the stomach quickly.
Can avoid by changing diet, eating smaller meals, and limiting high sugar foods.
Symptoms include: fast heart rate, sweating, nausea, diarrhea, or vomiting
118
What are some potential complications of
abdominal surgery?
■ Infection
■ Hemorrhage
■ Hernia
■ Bowel obstruction
■ Anastomotic leakage (leak where bowels join)
■ Dumping syndrome
■ Nutritional deficiencies
■ Increased risk of Death in first 3 months
119
What are some disadvantages to abdominal surgery?
■ High Cost
■ Waiting lists
■ Many eligible patients don’t want surgery
■ Large amount of resources pre- and post operation (other complications)
■ Potential need for body countering surgery
120
What are the psychological effects of abdominal surgery?
■ Grieve the loss of food
■ Increase in self esteem and self confidence
■ Changes in social circles
■ Difficulty with social and business functions that revolve around food
■ Resentment to suddenly improved social acceptance
121
What supports would someone getting bariatric surgery need?
■ Before surgery
■ After surgery
■ Psychological
■ Nutrition
■ Exercise
■ Skin flap surgery
■ Does it “fix” the underlying cause
122
What are the general results from surgeries?
■ 40% reduction in mortality
■ 50-90% reduction in incidence of diabetes
■ 55% reduction in coronary artery disease
■ 60% reduction in cancer (most, but perhaps ↑ colon cancer)
123
What is the connection between bariatric surgery and diabetes?
- Bariatric surgery causes significant weight loss and is more effective at improving diabetes in the short term (up to 2 years) than nonsurgical interventions (diet, exercise, behavioral interventions, medications).
- Diabetes improvement starts rapidly after surgery, before significant weight loss has occurred
- The mechanism for postoperative metabolic improvements may be independent of weight loss.
124
What is a Partial Diabetes Remission?
* Blood glucose below diabetes diagnosis thresholds: A1C <6.5%
* At least 1 year duration
* No hypoglycemic agents
125
What is a Complete Diabetes Remission?
* Blood glucose in normal range: A1C <5.7%
* At least year duration
* No hypoglycemic agents
126
What is a Prolonged Diabetes Remission?
* Blood glucose in normal range: A1C <5.7%
* At least 5 years duration
* No hypoglycemic agents
127
What did the Diabetes Surgery Summit consensus conference suggest?
Surgery should be considered for patients with inadequately controlled diabetes and a BMI as low as 30kg/m2 or 27.5kg/m2
128
What were the findings in the Metabolic surgery vs. Medical/Lifestyle intervention for diabetes remission?
* Despite variability between studies, surgery more effective than medical/lifestyle intervention for diabetes remission
* Decrease A1C by 2-3% (1-1.5% medical/ lifestyle groups)
129
What are the weight-independent glucose-lowering mechanisms of metabolic surgery?
1. Favourable changes in gut hormones
a) increased GLP-1 secretion and insulin
b) Compromised secretion of the diabetes-promoting peptide ghrelin
3. Increased glucose metabolism by small intestine
4. Changes in intestinal nutrient sensing that improve insulin sensitivity
5. Reduced intestinal glucose transport
6. Reduced circulating branched-chain amino acids
7. Possible alterations in gut microbiota
130
How much does bariatric surgery decrease the prevalence of metabolic syndrome?
34.8%
131
What is a major barrier with anti-obesity medications?
None of the anti-obesity medications have medical coverage (very rare)
132
How could weight loss medications work?
■ Decreasing hunger
■ Increasing satiety
■ Slowing digestion/absorption
■ Decreasing pleasantness of food
■ Decreasing absorption
■ Increasing metabolic rate
■ Increasing physical activity
133
Who cannot get medications?
Patients with:
■ a BMI > 30 kg/m2
■ a BMI between >27 kg/m2 with comorbidities
134
What is Orlistat: (Xenical)?
■ lipase inhibitor– decreases GI absorption of fat
- Inhibits the breakdown of fat so it passes directly through the digestive system.
■ Side effects:
- Flatulence
- Inability to control bowel movements
■ Other considerations?:
- May have a small effect on diabetes/ hypertension
- Long term adherence?
135
What are 4 types of weight loss drugs?
■ Orlistat - lipase inhibitor
■ GLP-1 analogue (structural homology): Liraglutide (inhibits feeding)
■ Saxenda® for obesity (used for type 2 diabetes, but different dose)
- Weight loss: up to 3.0 mg daily liraglutide injections
- Diabetes: 1.2 or 1.8 mg daily liraglutide injections
■ Likely causes weight loss by slowing gastric
emptying, satiety
136
What are the side effects for Liraglutide (Saxenda®)?
■ Headache, dizziness
■ Nausea
■ Diarrhea, constipation
■ Thyroid cancer
■ Pancreatitis/pancreatic cancer
137
What are some health considerations of Liraglutide (Saxenda®)?
■ Remove liraglutide from the market as the risk of thyroid cancer and pancreatitis outweigh benefits.
■ New drug – long term impact not well known
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What is Contrave?
- Combination of naltrexone and bupropion
- These medicines work on two separate areas of the brain that are involved in controlling eating (hunger and cravings)
- Contrave® is delivered in an oral tablet; at the maximum recommended dose, two tablets at twice daily
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Who is Contrave approved for?
- BMI of 30 kg/m2 or higher
- A BMI of 27 kg/m2 or above with the presence of at least one weight-related condition: hypertension, type 2 diabetes or dyslipidemia
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What are the known results of Contrave so far?
■ ~500 calorie reduction with PA and contrave
■ 60% of patients lost 5% or more of their body weight and kept is off for 56 weeks (in conjunction with diet and exercise)
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What is the "treatment gap"?
- In general, the malabsorptive procedures lead to more weight loss than the restrictive procedures after 36 months.
■ Roux-en-Y gastric bypass (RYGB): 40 - 50 kg
■ Adjustable gastric banding: 30 - 40 kg
- Medications
■ Orlistat OR Liraglutide: 3-5 kg
■ Semaglutide: >10kg
