Obesity Flashcards
(99 cards)
1
Q
Obesity - E/E
A
One of the most common d/o in medicine
According to WHO 500 million adults worldwide, 42 million children
Increased healthcare costs
Can be one of the most frustrating d/o to manage
Advances have been made with time
Continues to increase nationwide
Obesity stigma
Women > Men
68% of Americans are overweight based on BMI
Socioeconomic factors play a significant role
Ethnicity can have a major influence
Gentic predisposition
Medical condition
MULTIFACTORIAL!
2
Q
Genetics and obesity
A
Five gene identified
All affect control of appetite from a neuroendocrine standpoint
- Leptin
- Grehlin
3
Q
Economical Impacts of Obesity - Personal Level
A
$1,000's Additional medication cost Out-of-pocket healthcare expenses Costs related to inactivity Commercial weight loss program fees Additional food costs
4
Q
Economical Impacts of Obesity - National level
A
Billions yearly
5
Q
Economical Impacts of Obesity - Business level
A
More than $12 billion for employee care
5% of total healthcare expenditures
6
Q
Assessing obesity
A
EVERYONE!!
Record and trend BMI
Assess for co-morbid dz in anyone with a BMI of 25 or greater
7
Q
Obesity related Co-morbidities
A
DM-2 HTN OSA Dyslipidemia OA GERD Ca Back/joint pain Urinary stress incontinence Asthma OHS CAD / CHD NASH / NAFLD Pseudotumor cerebri Infertility - PCOS Psychological - Depression / Anxiety
8
Q
BMI of normal weight
A
18.5 - 24.9
9
Q
BMI of overweight
A
25 - 29.9
10
Q
BMI of Obese (Class I)
A
30 - 34.9
11
Q
BMI of Obese (Class II)
A
35-39.9
12
Q
BMI of extremely obese (Class III)
A
40+
13
Q
BMI
A
A measurement based on weight and height
Used to help determine the degree or severity of a person’s obesity
14
Q
Medical evaluation
A
Age of onset Weight changes FHx Social hx Occupational hx Eating habits Exercise habits Previous effeorts to address Assess for eating d/o - Laxative use - Diuretic use - Nutritional supplements
15
Q
Secondary Obesity
A
<1% have an attributable cause Hypothyroidism Cushing's dz or syndrome Other genetic conditions - Prader-Willi Syndrome - Alstrom Syndrome - Cohen Syndrome
16
Q
Weight loss strategies - in general
A
Dietary intervention Physical activity Behavior modification Drug tx Weight loss sx in the severely obese
17
Q
Weight loss strategies - Dietary intervention
A
About 10% of body weight and be healthfully lost in 6 months
Diets are prone to failure for many reasons
18
Q
Weight loss strategies - Physical activity
A
Increased activity can improve general health, but may have little impact on total body weight in morbid obesity
19
Q
Weight loss strategies - behavior modification
A
Can contribut to overall weight loss program
Requires ongoing professional contact
Failure rate can be high
20
Q
Weight loss strategies - Drug tx
A
Weight is typically regained when tx ends
21
Q
Weight loss strategies - sx
A
Weight loss sx in the severely obese
The most effective approach for long-term weight loss
22
Q
Dietary intervention - in general
A
Changing dietary habits
Daily Caloric intake
Long term success of dieting alone is poor
The higher the weight loss the harder it is to keep it off
23
Q
Dietary intervention - Changing Dietary Habits
A
Diets
Calorie counting
24
Q
Dietary intervention - Daily caloric intake
A
Requirements depend on numerous factors - Age - Sex - Physical activity - Health conditions Males: 2000-3000 /day Females: 1600-2400/day
25
Dietary intervention - Long term success
Only 20% will lose 20 lbs and keep it off for 2 years
26
Physical Activity
Calorie expenditure > intake
Typically a combination is best
5-7 days/week
Moderate Activity (100-130HR)
27
What is the best way to optimize fatty weight loss
A combination of diet and exercise
28
Behavior Modification
Esp. if weight gain is related to psychological eating d/o
Maintenance
Social support system!
29
Medications - in general
OTC & prescriptions
Routine f/u
Do they work?
30
Medications - NIH/FDA recommendations
Part of comprehensive program
BMI > 30
BMI > 27 if they have a medical co-morbidity
31
Medications - Examples
```
Xenical (Orlistat)
Belviq (Lorcaserin)
Phentermine
Topriamate
Saxenda (Liraglutide)
Qsymia
Contrave
```
32
Xenical (Orlistat)
```
Long term tx
TID with meals
MOA - GI tract
SE - GI
Risks - Malabsorption
2-4 kg > placebo
```
33
Belviq (Lorcaserin)
```
Shorter term tx
MOA - SSRA
Risks
- NMS
- Serotonin syndrome
- Breast tumors?
- Valvular HD?
3% > weight loss than placebo
```
34
Phentermine
```
Short term
Strict f/u is required
Two doses
- 15 mg
-37.5 mg
- QD 1-2h after breakfast
SE/risk
- Insomnia
- Fatigue
- CV
Better results
-7.8% & 9.8% > placebo
```
35
Topiramate
Anticonvulsant
Off label use for weight loss
Typical dose - 25mg BID
Black box warning - birth defects
36
Saxenda (liraglutide)
```
Injectable
Incretin (GLP-1 agonist)
FDA approved for weight loss
Dosage - 3 mg
SE - GI; Pancreatitis
Black box warning - carcinogen?
3.7-4.5% > loss than placebo at 1 year
```
37
Combination drugs
Qsymia
| Contrave
38
Qsymia
```
Phentermine / Topirmate
Dosage: 7.5/46mg; 15/92 mg
Contraindication: Hyperthyroidism; Glaucoma
SE
- Dizziness
- Paresthesias
- CV
- Psychologial
- GI
Black box warning - Birth defects
6.7% & 8.9% weight loss at 1 year
```
39
Contrave
```
Bupropion / Naltrexone
Dosage
- 8/90 mg
- Complicated dosing to start medication
- EDUCATE!
Risk / SE
- CV outcome in trial progress (HTN; tachycardia)
- GI
- Neuropsychiatric
2-4% > Placebo
```
40
Expectations of weight loss tx
```
Placebo
- 4-6% weight loss
- 0% (5 years)
Diet/behavior modification
- 8-12% weight loss
- 1.6% (10 years)
Drug therapy
- <10% weight loss
- 10% (5 years)
Gastric bypass sx
- 65-85% weight loss
- Up to 100% (5 years)
Lap. vert. sleeve gastrectomy
- 59% weight loss
- Up to 100% (5 years)
```
41
Bariatric surgery - in general
An option for individuals who have failed more conservative measures
The single most effective means of long terms weight loss
M/M risks in sx < non-sx obese pts with chronic dz
US and Canada > 100,000 / year
42
Bariatric surgery - Criteria
```
BMI > 40 w/o co-morbidity
BMI > 35 with obesity related co-morbidities
Must not have contraindications to sx
BMI 30-34.9 - metabolic
- Uncontrollable DM-2
- Metabolic syndrome
```
43
Bariatric surgery - Contraindications
```
No absolute contraindications
Anorexia nervosa or bulimia nervosa
Scleroderma (consider lap band)
Surgeon must exercise good judgment in selection
- Cirrhosis
- Previous sx
- Large ventral hernias
- large hiatal hernias
- various medical conditions (cardiomyopathy, stroke, sever coagulopathy)
- psychiatric illness
- OBD
- Connective tissue d/o
- Noncompliance
```
44
Bariatric surgery - Choosing a surgeon
Research
Resources
Organized program / multidisciplinary program - support groups
Center of Excellence (ASMBS)
45
Center of excellence
Training requirements
Procedure requirements - surgeon and facility
Hospital requirements - infrastructure
Program requirements - multidisciplinary
46
Bariatric surgery - Preparing the patient for surgical referal
Referral
Enroll in a multidisciplinary program
Pt seminar
47
Bariatric surgery - Pre-op requirements
```
Documented medically supervised wt loss w/o sig. reduction
Optimized co-morbidities
Behavior medicine
Dietary and exercise physiology eval
Meet with surgeon a minimum of two times
Assure pt's understanding f o post-op expectations
Pre-op testing
Pre-op low calorie diet
```
48
Bariatric surgery - Procedures in general
Restrictive
| Combination
49
Bariatric surgery - Restrictive procedures
Sleeve gastrectomy (LVSG)
Adjustable gastric banding (AGB
Vertical banded gastroplasty (VBG)
50
Bariatric surgery - Combination procedures
```
Roux-en-Y gastric bypass
Biliopancratic diversion (BPD)
Duodenal switch (DS)
```
51
Adjustable gastric banding - Advantages
```
AGB
Not permanent
Less short term complications
Quick recovery
Same anatomy
20-50% EBWL
Lowest mortality and complication rates
```
52
Adjustable gastric banding - Disadvantages
```
Foreign body
Frequent f/u
60% re-operation rate
Long-term complications high
Many require removal
```
53
Adjustable gastric banding - Complications
```
Dysphagia
N/V
Pain (epigastric & port site)
GERD
Aspiration
Band leak
Band slippage
Band erosion
Port leak
Flipped port
Esophageal dilation
```
54
Roux-en-Y Gastric Bypass - In General
```
RNYGB
Overall very good weight loss
Combo procedure - restrictive and malabsorptive
Higher risk but better return
Instant improvement in DM/hyperglycemia
Less frequent f/u than AGB
Must monitor long-term for deficiencies
- Risk for hypovitaminosis
- Dependent upon length of limbs
```
55
Roux-en-Y Gastric Bypass - Advantages
```
Rapid initial weight loss
Less frequent f/u required
No implant
Laparoscopic approach
Longer track record in US
```
56
Roux-en-Y Gastric Bypass - Disadvantages
```
Stomach cutting, stapling and intestinal rerouting requires
Risk for hypovitaminosis
Higher short term complications and mortality rates than LAP-BAND
Potential for nutritional deficiencies
"Dumping syndrome" can occur
Not adjustable
Difficult to reverse
Longer hospital stay and recovery
```
57
Dumping syndrome
Massive insulin release b/c of something the pt ate
58
Roux-en-Y Gastric Bypass - Complications (early)
```
Pneumonia - 0.14%
Oxygen insufficiency - 0.48%
Leaks - 2.05%
Wound infection - 2.98%
GI Bleeding / hemorrhage - 1.93%
PE - 0.41%
Bowel obstruction - 1.73%
Death - 0.23%
N / V
```
59
Roux-en-Y Gastric Bypass - Complications (late)
```
Strictures - 4.73%
Incisional hernia (laproscopic) - 0.47%
Incisional Hernia (Open sx) - 8.58%
SBO - 3.15%
Anemia & B12 deficiency
Ulcers / gastritis
Cholelithiasis
Internal hernia / intestinal ischemia
```
60
Roux-en-Y Gastric Bypass - complications (leaks)
Rare, but can occur at any 5 internal staple line
pH of gastric content is very irritating to lining of abdomen and internal organs
Can quickly lead to sever infection, septic shock
Death may result
Re-operation required to find and repair the leak
Early detection and tx is key!!!
61
Most common leak site of the Roux-en-Y Gastric Bypass
Pouch to intestine
62
Roux-en-Y Gastric Bypass - Outcome
```
60-70% EBWL
>75% control of co-morbidities
- DM-2 83.8% resolution
- HTN 75.4% resolution
- OSA 86.6 resolution
```
63
Roux-en-Y Gastric Bypass - Supplementation
Adult multivitamin
Vit. B12
Calcium (citrate) plus Vit, D
Iron on occasion
64
Laproscopic Vertical Sleeve Gastrectomy - In general
```
LVSG
Descendant of the BPD and DS
Initially used as a staged procedure
Restrictive only - endocrine influence
Maintain continuity
Risk < RNYGB
Risk > AGB
Still recommend supplementation however for low risk for hypovitaminosis
```
65
Laproscopic Vertical Sleeve Gastrectomy - Grehlin influence
Member of Motilin family of gut peptide hormones
Ligand for growth hormone secretigogue receptor
90% secreted in stomach and duodenum P/D1 cells
66
Function of Grehlin
Increase GH secretion
Increase food intake
Weight gain
67
Laproscopic Vertical Sleeve Gastrectomy - Advantages
```
Laparoscopic
May be an option for carefully selected pts, including high-risk or super-super-obese pts
Mean excess weight loss at 1yr of 59%
No implanted medical device
Less frequent f/u required
Maintain continuity
```
68
Laproscopic Vertical Sleeve Gastrectomy - Disadvantages
Stomach cutting adn stapling required
Not reversible
Inpatient hospital stay and somewhat longer recovery than gastric band
Insurance
69
Laproscopic Vertical Sleeve Gastrectomy - Complications (early)
```
Hemorrhage (0.7-1.8%)
Leaks (0.7-0.8%
Death (0.39%)
Wound infection
PE
Pneumonia
Oxygen insufficiency
Stenosis
```
70
vLaproscopic Vertical Sleeve Gastrectomy - Complications (late)
```
Structure
Acid reflux
Incisional hernia
SBO
Ulcers / gastritis
Cholelithiasis
```
71
Laproscopic Vertical Sleeve Gastrectomy - Outcomes
Good weight loss and long term results
55-65% EBWL
Resolution of co-morbidities come with weight changes
Slower results but still excellent resolution potential
72
Biliopancreatic Diversion with Duodenal Switch - in general
BPD-DS
Initially started as BPD alone
Pt selection is key
Close f/u is a must
73
Biliopancreatic Diversion with Duodenal Switch - modifications
DS
Sleeve
Laparoscopic approach
74
Biliopancreatic Diversion with Duodenal Switch - Advantages
Very rapid inital weight loss
Weight loss continues beyond 12m at a slower rate
No foreign body
Very good resolution of co-morbidities
Best EBWL of any wt loss procedure
Now laparoscopic and robotic approaches available
Good option for wt loss in super morbidly obese (esp. BMI>60)
75
Biliopancreatic Diversion with Duodenal Switch - Disadvantages
```
Non-reversible
Staling/cutting of viscera
Hypovitaminosis
Close f/u requires
Longer hospital stay
Long term nutritional monitoring a must
```
76
Biliopancreatic Diversion with Duodenal Switch - Complications (early)
```
Higher mortality - 30d rate 2.6-7.6%
Anastomotic leak
Duodenal stump leak
Intra-abdominal abscess
Hemorrhage
VTE
Bowel obstruction
N/V
```
77
Biliopancreatic Diversion with Duodenal Switch - Late
```
Bowel obstruction
Internal hernia
Structure (2 locations)
Nutritional deficiency
- Iron
- Calcium / Vit. D
- B12
- Folate
- Fat soluble vitamins in certain situations
Diarrhea
Cholelithiasis
```
78
Biliopancreatic Diversion with Duodenal Switch - Outcomes
```
EBWL 70-80%
DM-2 - 90% resolution at 12-36m
HTN - 50-80% resolution
OSA - 98% resolution
Dyslipidemia improvment / resolution
Better outcomes than any other procedure
```
79
Vertical Banded Gastroplasty - In General
VBG
Not routinely performed any longer
Still a sig. amount of pts around
80
Vertical Banded Gastroplasty - common complications
Staple line breakdown (gastrogastric fistula)
Gastric outlet obstruction
Incisional hernia
81
Other weight loss surgeries - Types
Vagal N. stimulators
Gastric plication
Band over
Endoscopic gastric balloon
82
Complications - N/V
| In general
Often the most common complaint after sx
Typically acute post-op but can become chronic
Places at risk for dehydration post-op
83
Complications - N/V
| Tx
```
First line
- Zofran
- Reglan
- Phenergan
- Compazine
Second line
- Decadron
- Levsin
- Marinol
```
84
Complications - Reflux
| In general
More common in LVSG
| Signifies underlying pathology in RNY/BPD but can be a sign of pathology with LVSG
85
Complications - Reflux Associated complications
Ulcer
Stricture
Gastrogastric fistula
86
Complications - Reflux
| Work-up
UGI
EGD
24h pH - in select cases
87
Complications - Reflex
| Tx
PPI +/- Carafate
| Sx to correct complication or to alleviate
88
Complications - Anastomotic ulcer
| In General
Common late complication of RNYGB, BPD
| Located at the gastrojejunostomy
89
Complications - Anastomotic ulcer
| Dx and Tx
DX - EGD
TX
- Educate
- Referral back to bariatric surgeon
- PPI
- Carafate
- Sx
90
Complications - Strictures
| In General
Can be seen in RNYGB, LVSG, BPD-DS
Often associated with smoking
RNY - gastrojejunostomy, jejunojejunostomy
LVSG - Insisura, GE junction (Angle of His)
BPD/DS - Duodenojejunostomy
91
Complications - Strictures
| Tx
STOP SMOKING!!!
PPI
EGD with dilation
Sx
92
Complications - internal hernia
Can arise at any of the multiple mesenteric defects associated with any malabsorptive procedure
Must be a consideration in these pt with chronic post-prandial abdominal pain
Place pt at risk for an acute ischemic event involving affect segments
93
Complications - internal hernia
| Work-up and Tx
Work-up
- Work-up may be negative
- UGI / Small Bowel series
- EGD
- CT abdomen and pelvis with contrast
- Diagnostic laparoscopy
Tx - sx (open vs. laparoscopic)
94
Complications - Post-op
| In general
Long term success is dependent on f/u
Monitor for short and long term complications
Monitor dietary habits, exercise habits, aid in accountability
Should see surgeon frequently in 1st year
95
How often should post-op f/u for bariatric sx occur?
1 week
1 month
Quarterly
F/u yearly thereafter
Routine dietary, exercise and psychology f/u is a must
96
Complications - Hypovitaminosis
Can be due to procedure
Can have influence from complications post procedure
Long term actid suppression meds can influence
Key players - B12, Magnesium, Calcium
97
Supplementation - ASMBS Guidlines
```
Lifelong supplementation for all bariatric sx pts
Adult multivitamin
- Vit B12
- Iron
- Vit A
- Vit D3
- Folic Acid
- Thiamine (B1)
- Zinc
- Copper
- Vit C
- Biotin (optional)
Calcium / Vit. D
Vit. B12 - RNYGB, BDP-DS, Sleeve?
```
98
PCP role - Pre-op
Assess all individuals at risk
Optimize medical conditions related to obesity
Medially managed weight loss regimen
Referral for behavior modification
Medications
Initiate referral process for bariatric sx
DOCUMENT
99
PCP role - Post-op
Good communication with specialists - labs
Early and frequent f/u initially
Routine f/u long term
Co-morbidities
Be able to identify early and lat complications
Long-term nutritional mainentance
Refer back to bariatric surgeon with complications
If symptoms arise think common things but never forget to assess their post sx anatomy
