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Obesity Flashcards

Learn basic weightloss management medicine and techniques (807 cards)

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1
Q

Contrave (wellbutrin/naltrexone) dosing

A

90mg/8mg

Ramp up weekly 1 tab po qam, 1 tab po bid, 2 tabs qam and 1 po qpm, 2 tabs po bid

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2
Q

Contrave contraindications

A
  • seizure disorder
  • opiate use
  • uncontrolled HTN
  • within 14 days of MAOIs
  • caution is current alcohol or bzd use
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3
Q

Contrave actions

A

Good if food cravings and addictive behavior, depression, smoking cessation,
other substance cessation

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4
Q

Liraglutide (saxenda) dosing

A
  • GLP-1 agonist
  • 5-10% wt loss
    Victoza dose for dm2 only up to 1.8 mg
    Saxenda dose is 3 mg (studies haven’t been done to assess cardiovascular
    prevention)
    • Start at 0.6 mg and go up by 0.6 mg weekly up to 3 mg, but many
    people can’t always do the full titration due to SEs
    D/c if <4% body weight after 16 weeks at 3 mg
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5
Q

Liraglutide contraindications

A

pancreatitis, family or PH medullary thyroid cancer (MEN-2)

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6
Q

Lorcaserin dosing

A

No generic, so more costly

  • can get up to 10% wt loss
  • start 10 mg ER before dinner
  • 10 mg bid or 20 mg ER daily
  • stop if <5% wt loss at 12 wks
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7
Q

Lorcaserin SEs

A

HA, dizziness, fatigue, nausea, dry mouth, constipation

though SEs low with this medication

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8
Q

Lorcaserin contraindications

A
  • Theoretic risk of valvulopathy (prior seen in Phen-phen), but not same receptor
    affinity as lorcaserin
  • Risk for serotonergic over-activity, avoid prescribing with other serotonergic
    agents
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9
Q

Qysmia (phentermine/topamax) dosing

A
  • if dosing separately, give phentermine in AM and topamax 1 hr prior to dinner (helps with nighttime eating)
  • Start 3.75 for 2 weeks then 7.5 for 1 month, then may escalate up each
    month
    • 3.75 is considered acclimation dose, not the one that really achieves weight loss. Some may benefit from it as maintenance though
    • 7.5/46 is considered normal maintenance dose, most people achieve
    weight there. Higher doses are for people not losing weight
    ▪ Stop if not 5% weight loss after 12 weeks on maximum dose
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10
Q

Qysmia contraindications

A

uncontrolled HTN, CAD, glaucoma, nephrolithiasis,

insomnia, anxiety, okay if well-controlled HTN with close monitoring

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11
Q

Qysmia SEs

A

dry mouth, paresthesia, constipation, abn taste in mouth, insomnia, glaucoma
- metabolic acidosis
- elevated Cr
▪ Gradual escalation of doses, helps minimize SEs

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12
Q

Adult overweight

A

BMI 25-29.9

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13
Q

Adult class 1 obesity

A

BMI 30-34.9

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14
Q

Aduly class 2 obesity

A

BMI 35-39.9

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15
Q

Adult morbid obesity, class 3

A

Bmi>/=40

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16
Q

Pediatrics overweight

A

BMI 85th-95th%

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17
Q

Pediatric class 1 obesity

A

BMI 95th-120th%

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18
Q

Pediatric class 2 obesity

A

BMI 120th-140th%

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19
Q

Pediatric class 3 obesity

A

BMI >140th%

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20
Q

Obesity definition

A

chronic, progressive, relapsing, multi-factorial neurobehavioral dz causing inc adiposity leading to metabolic and psychosocial health consequences

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21
Q

Adiposopathy/Sick fat disease

A

pathogenic adipose tissue causing endocrine and immune dysfunction

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22
Q

Fat mass disease

A

Pathogenic forces from excessive body fat cause stress damage on body

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23
Q

Functional foods definition

A

Nutrients with potentially favorable effects outside of basic nutrition (ie complex carbs provide heart health)

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24
Q

Non-obesity causes DM2

A
  • hemochromatosis
  • hypercortisolism
  • excessive growth hormone
  • pancreatic insufficiency
  • SE of medication
  • genetic syndromes
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25
Non-obesity causes HTN
- pheo - primary hyperaldosteronism - hypercortisolism - hyperthyroidism - RAS - CKD - SE of meds - genetic syndrome
26
Non-obesity causes dyslipidemia
- Hypothyroidism - poorly controlled DM2 - liver dz - CKD - SE of medication - Genetic dyslipidemia
27
Mech of obesity, insulin resistance, and metabolic dz
Positive caloric balance and adiposopathy--> inc free fatty acids (FFA)--> fat deposition in liver and muscles--> dysfunction, inc insulin resistance--> hyperinsulinemia, pancreas dysfunction, inc BG, HTN, dyslipidemia, CAD, CA--> worsens obesity and adiposopathy
28
1st major organ affected by adipose deposition
- often the liver
29
Body fat distribution
- pericardial - intracardial - Visceral - Hepatic and skeletal m fat
30
CVD outcomes and anti-obesity medications
No AOM proven to improve cardiac outcomes | - GLP1 do help in DM2, studies being done with obesity
31
locarsarin health benefits
- may help dec rate of DM2 or rate/progression of CKD
32
Medication for obesity with CVD
- nutrition/exercise | - no medications are really contraindicated in CVD
33
Semaglutide
- used to tx DM2, SE of weight loss - PIONEER trial looking at oral administration - SELECT trial looking at CVD prevention in obesity
34
Most common M&M in obesity
CVD
35
patient first language
Pt who is overweight or obese preferred over "obese patient"
36
Obesity as multifactorial disease
Involves: - genetics/epigenetics - neurobehavioral - medical - endocrine - environment (social/culture) - immune
37
Extragenetic causes obesity
- environment (family, geography) - culture - poor nutrition/PA - disrupted sleep (too little or too much) - medication SEs - stress - neurologic dysfunction - viral infections - gut microbiota, pro-inflammatory state
38
Epigenetics definition
Alteration in gene expression without alteration in genetic code - occurs pre-pregnancy, intrautero, and post-pregnancy
39
Pre-pregnancy epigenetics
Pre-conception weight of both parents can influence signalling in pregnancy - inc risk overwt/obese children - inc risk CAD, CA, DM, etc in children
40
Pregnancy epigenetics
GDM and poor maternal nutrition, overwt/obese increases nutrient transfer to fetus (glucose, aa, lipids, FA) - both under weight and overweight inc risk of obesity - smoking and stress inc risk
41
Result of inc nutrient transmission to fetus
- modifications in gene expression - change in stem cell fate - Alter postnatal substrate metabolism - inc risk for overwt, obesity
42
Sick fat disease
Adiposopathy - inc BG - HTN - HLD - other metabolic dz
43
Fat mass disease
- stress on joints - immobility - tissue compression (OSA, GERD, HTN) - tissue friction (intertrigo, etc)
44
Overall management goals for obesity
- improve overall health - improve QOL - improve BW and composition
45
Essential fat values
women 10-13% | men 2-5%
46
athlete fat values
women 14-20% | men 6-13%
47
fitness fat values
women 21-24% | men 14-17%
48
acceptable fat values
women 25-31% | men 18-24%
49
obesity fat values
women >/=32% | men >/=25%
50
Abdominal obesity men
>/=40 inches
51
abd obesity women
>/= 35 inches
52
abd obesity asians
women >/= 31.5 | men >/=36
53
Codes for obesity
- Code first if obesity complicating pregnancy, etc, then BMI code - E66- overweight/obesity and specify type
54
Best measure of obesity
- BMI is good screening measure - WC helps to determine weight distribution and worse metabolic outcomes - %BF good to look at extremes of m mass (ie sarcopenia or inc m mass) that may skew BMI number
55
Cardiovascular fat mass dz
- CHF, cor pulmonale - HPfEF - Varicose veins - DVT, PE, CVA - HTN
56
Pulmonary fat mass dz
- Dyspnea - OSA - Hypoventilation syndrome - Asthma
57
Neurologic fat mass dz
- Intracranial HTN (psueudotumor cerebri) - CVA - n entrapment
58
MSK fat mass dz
- immobility - arthritis - back pain - myalgias - impaired balance
59
GI fat mass dz
- GERD | - hernias
60
Integument fat mass dz
- striae (stretch marks) - stasis pigmentation - venous stasis ulcers - skin tags - intertrigo - carbuncles
61
Metabolic manifestations adiposopathy
- inc BG - HTN - metabolic syndrome - HLD - fatty liver - hyperuricemia/gout - cholelithiasis - acanthosis nigricans - nephrolithiasis - glomerulonephropathy - neuropsych dz - asthma - OA - CAD
62
adiposopathic dyslipidemia
- inc TG - low HDL - inc apolipoprotein B (atherogenic prot) - inc LDL - inc lipoprotein remnants
63
Female issues adiposopathy including pregnancy
- hyperandrogenism - hirsutism - acne - PCOS - infertility - menstrual irregularities - GDM - PreE - thrombosis - inc risk miscarriage or stillbirth - inc need for IOL - inc risk with C/s healing and infection - LGA babies
64
Male issues adiposopathy
- hypoandrogenemia - hyperestrogenism - ED - low sperm count - infertility
65
Obesity associated CA
- bladder - brain - breast - cervical - colon - uterine - GB - esophageal - renal - leukemia - liver - MM - non-hodgkin lymphoma - ovarian - pancreatic - prostate (prognosis is worse) - stomach - thyroid
66
Emergent fight/flight response
Occurs in time of acute stress, inc sympathetic activity: - inc catecholamines (E, NE) - inc BP - vasoconstriction - inc HR and contractility - dec blood flow to kidneys - bronchial dilation - inc in glucose levels - inc adipose tissue lipolysis
67
Endocrine response to chronic stress
Submit and stay response by hypothalamic pituitary axis activity: - inc corticotropin-rel horm - inc adrenocorticotropin - inc arginine, vasopressin, and oxytocin - inc cortisol
68
response to inc cortisol
- inc BG - inc BP - inc food cravings - inc adipose tissue lipolysis and m tissue wasting - inc accumulation of abd fat
69
Immune response to acute stress
catecholamine mediated: - enhance immune sys - demarginalization WBC - inc adaptive immune response and T cell activity
70
immune response to chronic stress
Glucocorticoid mediated - dysregulation of immune sys - inc total WBC with inc systemic inflammation - dec immune resp and T cell activation
71
Chronic stress and eating behaviors
Affects limbic system (thalamus, hypothalamus, amydala, and hippocampus) and cerebrum - enhances desire for hyperpalatable foods
72
Adiposopathy stress cycle
- Become obese and metabolic dz - cause chronic stress - leads to behavior change, endocrinopathy, and immunopathy - leads to inc body fat - worsening adipose tissue dysfunction - which leads to more obesity and metabolic dz causing a cycle
73
history for obesity visit
- screen for fat mass dz - screen for adiposopathy dz (DM2, HTN, etc) - eating disorder screen - mental stress - sleep - medications associated with weight gain - smoking - alcohol - drugs - weight pattern over lifetime - previous attempts to lose weight, barriers or successes
74
FH for obesity visits
- other obese family members | - Medical dz related to obesity
75
SH for obesity visits
- availability of healthy food- who buys - access to physical activity - economic status - social status - culture - occupation - family structure - living situation - abuse - geographic location
76
Nutritional hx for obesity visits
- timing and frequency of meals - where do they eat meals - location of away food consumption - access to foods - preparer of foods - nutritional content - triggers for eating - nighttime eating activities - binge eating/emotional eating
77
Physical activity history
- success/failures for previous attempts - barriers to previous attempts or engaging now - current PA (FITTE)- frequency, intensity, time of duration, type, enjoyment - current fitness level and mobility - equipment needs - access to locations
78
VS/weight measure for obesity visit
- Ht/Wt - BMI - waist circumference (using superior iliac crest) - BP - Pulse - neck circumference
79
Routine lab testing at obesity visit
- fasting BG - A1c - lipids - LFTs - BMP - uric acid? - TSH - Vit D - CBC - UA, urine micro/Cr
80
Individualized labs in obesity
Based on suspected 2/2 causes - glucose tolerance testing - fasting insulin, proinsulin, and C peptide - Dexamethasone suppression test - midnight salivary cortisol - prolactin, estradiol, FSH, LH, preg test - Testosterone, DHEA-S - apolipoprotein B - iron studies - CRP
81
Individualized imaging in obesity
- MRI or CT brain - EKG - stress test - echo - ABI - sleep study - liver u/s - resting metabolic rate
82
Ways to test body composition
- DEXA - bioelectric impedence - whole body air displacement plethysmography - myotape - caliper % body fat - underwater weighing - quantitative MR - CT
83
Emerging tests for obesity
- leptin - leptin-adiponectin ratio - FFA - TNF - IL 1 and 6 - gut microbiota - adenovirus assays
84
fat free mass
total body mass minus any body fat | - includes water, mineral, prot, and glycogen
85
Lean body mass
total body mass minus non-essential or storage adipose tissue - includes water, mineral, protein, glycogen, essential fat in organs, CNS, and bone marrow
86
Difference between fat free and lean body mass
differs only by about 5% - little less in men - little more in women
87
TBM calculation
= fat mass + lean mass + bone mass
88
Lean mass calculation
= total mass - fat mass- BMC
89
% body fat calculation
= fat mass/ (total body mass-bone mass)
90
Calipers to measure body fat
- user dependent, results can vary widely | - not optimal if very high BMI
91
DEXA to measure body fat
- accurate - relatively inexpensive - not all differentiate visceral vs SC fat - not all accomodate very high BMI in machine
92
Gold standard for body fat composition measure
- DEXA | - gives % body fat, android fat (SC and visceral), lean body mass, and BMD
93
Total energy expenditure
In mod physical inactivity people: - 70% resting metabolic rate - 20% physical activity - 10% diet induced thermogenesis
94
Meds that can inc body weight
- beta-blockers (propranolol, atenolol, metoprolol) - CCB- nifedipine, amlodipine, felodipine - insulin - SUs - TZDs - meglitinides - steroids - E - progestins (injectables have greatest risk) - Testosterone - carbamazepine - gabapentin - depakote - lyrica - TCAs - doxepin - lithium - antipsychotics - benadryl - aromatase inhibitors - tamoxifen - methotrexate - SSRIs- paxil, celexa, lexapro (variable), zoloft (variable) - SNRIs- duloxetine, venlafaxine - mirtazipine
95
DM Meds that can dec body weight
- metformin - GLP1 agonists - SGLT-2 inhibitors - alpha glucosidase inhibitors - pramlinitide
96
Anti-seizure meds that may dec weight
- lamictal - topamax - zonisamide
97
Antidepressants that may dec weight
- wellbutrin - prozac (variable) - nortriptyline has no weight change
98
carbohydrates general
- contain 4 kcal/g - source of energy and used for cellular structure - non-essential since liver can synthesize glucose - broken down into monosaccharides - may contain sugar, starch, and fiber - no known carbohydrate def dz - DRI for carbs is 130 g/day
99
Fat general
- contains 9 kcal/g - used as energy source for immune response, cell membrane structure, brain tiss, synthesis of bile acid, cholesterol, vit D, and hormones, insulation - need essential fatty acids that body cannot synthesize - DRI at least 30 g/day - replacing saturated with polyunsaturated or monounsaturated dec cardiovascular risk
100
Protein general
- contains 4 kcal/g - contain AA and are major structural building block in body - essential AA cannot be made by the body and must be consumed - some used as energy source (made to glucose and ketones) - def leads to kwashiorkor - DRI 0.8-2g/kg/d
101
Insulin affect on body
- promotes FA and TG synthesis (lipogenesis) and storage - inhibits fat breakdown (lipolysis) - limiting foods that stimulate rise in insulin helps promote weight loss
102
Very low-calorie diet
<800 cal/day - requires close medical supervision for safety - recommended for short duration - utilize full meal replacements to make sure getting all essential nutrients in the caloric intake
103
Low calorie diets
- women 1200-1500 | - men 1500-1800
104
Fat restriction and cholesterol
More reduction in total cholesterol and LDL
105
Carb restriction and cholesterol
More reduction in TG and inc in HDL
106
Types restricted fat diets
- low fat diet | - very low fat diet
107
low fat diet definition
<30% fat calories
108
very low fat diet definition
<10% fat calories
109
types restricted carb diets
- low glycemic diet - low carb diet - very low carb diet
110
Low carb diet definition
50-150 g/day
111
Very low carb diet definition
<50 g/d with or without nutritional ketosis
112
Low carb diet weight loss
- modestly greater wt loss than fat restricted by 6 mths, then after is similar - may help with food cravings
113
low carb diet metabolic effects
Effects can occur with or without wt loss - dec fasting gluc and TG - Inc HDL - Inc LDL - Dec BP - may help dec DM complications (ie neuropathy)
114
Risks low carb diet
- May cause inc carb cravings during first fe w days - inc gout flares - malaise
115
Wt loss low fat diet
- after 6 mths same as carb restriction
116
Metabolic effects low fat diet
- dec glucose and insulin dec LDL - dec BP
117
Risks low fat diet
- hunger control can be challenge | - may substitute higher carb foods which can lead to hyperglycemia and inc cholesterol
118
Wt loss very low calorie diet
- rapid weight loss
119
Metabolic effects very low calorie diet
- dec gluc, TG, LDL - inc HDL - Dec BP
120
Risks very low calorie diet
- fatigue, nausea, constipation, diarrhea, brittle nails - cold intolerance - dysmenorrhea - sm inc GB and kidney stones, gout flares - cardiac dysrhythmias, m cramps - wt regain will occur if not transitioned proprerly
121
Trans fats
- artificially created to inc melting temps of fast - inc LDL, dec HDL - inc cardiac dz, DM and CA - FDA has banned them, but can still be found in some products
122
Mediterranean diet
Describes meal patterns seen in Greece, Italy, and Spain - dec cardiac risk - olive oils - veggies, fruits - legumes, nuts, seeds - whole grains - mod intake red wine - mod consumption seafood, fermented dairy products (cheese, yogurt), chicken, and eggs - limits red meat and sweets
123
Therapeutic lifestyle diet
Low fat meal plan, used most in lipid trials - total fat 25-35% daily calories - polyunsaturated fat up to 10% - carbs 50-60% - 5-10 g fiber/day - 2 g/day plant stanols or sterols - avoid trans fat and limit saturated fat to <7%
124
Ketogenic diet
Carb restricted diet, promotes using fat for energy and making ketosis - induction phase: <20 g carbs/d from non-starchy veggies, adequate protein, and inc fat - weight loss phase: allows more variety of veggies, seeds, and nuts and low-glycemic fruits - premaintenance phase: carb intake slowly inc - maintenance phase: 60-90 g carbs/d - avoid processed and refined foods and trans fat - most phases limit grain carbs, dairy (except cheese), starchy veggies, and most fruits
125
Ornish diet
fat restriction diet - encourages foods in natural form - 1 serving soy product/d - limited amts green tea - fish oil each day - small frequent meals - avoid sugar, sodium, alcohol, meat, caffeine, trans fats, refined carbs - limit fat <10%/d
126
DASH diet
Used for cardiac and HTN - encourage fruits/veggies, and whole grains - fat free dairy products - fish, chicken, and lean meats - nuts, seeds, legumes - fiber, Ca, Mg, K - limit Na to 1500-2300 mg/d - limit fat <27% - limit saturated fat <6% - avoid red meat, sugary foods and beverages
127
Paleolithic diet
Based on diet pattern from paleolithic period - encourage veggies, fruits, and root veggies - lean red meat, seafood - eggs, nuts, seeds - healthy oils - Avoid grains, potatoes, processed foods, refined sugars and oils, legumes. dairy
128
Vegan
- only plant based foods, no animal proteins or products (eggs, milk, honey)
129
Lacto-vegetarian
plant foods plus dairy
130
lacto-ovo vegetarian
plant foods, dairy, and eggs
131
pescatarian
plants and seafood
132
Advantages intermittent fasting
- helps dec decision making about food - can fit better in schedule - dec calories but preserves lean body mass - lose weight and improve metabolic outcomes
133
Disadvantages intermittent fasting
- doesn't emphasize healthy eating - not good if eating disorder - may not be sustainable - inc risk hypoglycemia in DM - may inc gout, nephrolithiasis, and dysrhythmias - lot of long-term studies based on animal models
134
Physical activity and adiposopathy
- helps with weight loss and maintenance - improves adiposopathic psychological problems - inc insulin sensitivity - inc mitochondrial function - inc browning of fat cells
135
PA for those unable to walk
- chair exercises - arms with cycling or bands - swimming/acquatic - gravity mediated - PT
136
PA for limited mobility
- walking - swimming/aquatic - gravity mediated
137
Dynamic/aerobic PA and wt loss
Recommend 150 min/wk mod intensity or 75 min high intensity | - >300 min mod or 150 high leads to more wt loss and dec regain
138
Types physical activity
- dynamic/aerobic - resistive strength/anaerobic - leisure activities - NEAT (non-exercise activity of transportation)
139
Exercise prescription
FITTE - frequency - intensity - time spent - type - enjoyment - may add volume of exercise and progression
140
Stages of change
- precontemplation - contemplation - preparation - action - relapse
141
focus of MI
- collaborate to find and implement solutions - evoke patients' feelings and ideas - autonomy- empower pts to own their solution
142
principles of MI
- express empathy - avoid argumentation - develop discrepancy - resolve ambivalence - support self-efficacy
143
5 As of obesity management
- Ask - Assess - Advise - Agree - Arrange/assist
144
Ask 5As
- ask permission to discuss weight | - explore readiness
145
Assess 5As
- look at BMI, WC | - explore drivers and complications of excess weight
146
Advise 5As
- talk about health risks and benefits of modest wt loss (5-10%), and tx options
147
Agree 5As
- set realistic expectations for wt loss, behavior changes, goals, and tx plan
148
Arrange/assist 5As
- identify and address barriers - give resources - arrange f/u
149
Why do people eat too much
- biologic forces resisting wt loss and promoting wt gain - hypothalamic dysfunction - hunger before meals - lack satiety after meals - triggers in environment - eating as reward - feeling obligation - advertising - lack of knowledge
150
Binge eating disorder
- episodes of eating large amounts of food >1x/wk for at least 3 mths - no purging - feels lack of self control, shame, and guilt - 2-3% of adults - most common eating disorder - Eating attitudes test can help diagnose
151
Tx binge eating disorder
- CBT - lisdexamfetamine - non-FDA approved: SSRIs, topomax
152
Bulimia Nervosa
- cycle of recurrent binge eating and purging - 1% adults - can have hypoK, hypoMg
153
russell sign
calluses and abrasions on dorsum of hands due to repeated contact with teeth in purging
154
Tx bulimia
- prozac | - non-FDA: topamax, naltrexone
155
night-eating syndrome
- at least 25% of daily food consumed after evening meal - waken from sleep and eat to get back to sleep - often carb rich snacks - little interest in breakfast - 5% population
156
Why do people regain bodyweight
- body strongly resists undernutrition - wt loss decreases leptin, insulin, cholecystokinin, and peptide YY which increases appetite - wt loss cause inc ghrelin which increases appetite - exercise may inc sensitivity to insulin and leptin - lack of maintenance of PA - dec resting energy expenditure - greater m efficiency, so less resting expenditure - people go back to previous habits or lack of PA
157
BMI requirement for obesity medications
- BMI >30 | - BMI >27 with co-morbidities
158
When non-responder
<4-5% wt loss on maximum therapy for 12-16 weeks depending on medication
159
Wt loss expected with AOM
5-10%
160
phentermine
- sympathomimetic amine - approved for short-term use (12 weeks) - 5% weight loss
161
phentermine SE
- HA - HTN - arrhythmia - tremor - insomnia
162
phentermine contraindications
- uncontrolled BP - seizure d/o - h/o CAD - within 14 days of MAOIs - glaucoma - drug abuse
163
Orlistat
- GI lipase inhibitor, impairs digestion of fats - OTC - 5% wt loss - dosing 120 mg tid qAC
164
Orlistat SEs
- oily leaking - flatus - inc gallstones or kidney stones - malabsorption fat soluble vitamins (beta carotene, vit K, A, D, E) - rare iiver injury and pancreatitis * Recommend taking MTV to prevent deficiencies
165
Orlistat med interations
- cyclosporine - OCPs - seizure meds - thyroid meds - warfarin - Vit K levels tend to decline
166
lorcaserin
- 5HTP 2c rec agonist - helps with sense of fullness - 5-10% loss - dose 10 mg bid for IR or 20 mg qd for ER - metabolized in liver and excreted in urine
167
lorcarserin SEs
- HA - dizziness - fagitue - nausea - confusion - euphoria/dissociation - priapism - bradycardia - leukopenia/anemia (monitor CBC periodically) - dry mouth - constipation - risk serotonin syndrome, NMS, heart failure, psych disorders, and priapism
168
lorcaserin drug interactions
- SSRIs - SNRIs - MAOIs - anti-dopaminergic meds - St. John's Wort - triptans - buproprion - dextromethorphan
169
liraglutide SEs
- nausea, dyspepsia - hypoglycemia - diarrhea, constipation, vomiting - HA - dec appetite - fatigue, dizziness - CKD
170
Liraglutide contraindications
- MEN type 2 - medullary thyroid CA or FH of - pancreatitis - GB disease - SI
171
Naltrexone SEs
- nausea, constipation, HA, vomiting, hepatitis and liver failure, dizziness, insomnia, dry mouth, diarrhea, glaucoma
172
Contrave drug interactions
- opiates - seizure meds - MAOs
173
Qysmia drug interactions
- MAOIs | - may alter OCP absorption
174
supplement definition
- substances taken in addition to dietary intake
175
function food definition
- nutrients in foods with potentially favorable effects beyond nutrition
176
Hepatotoxicity related to supplements
- account for 20% of cases of hepatotoxicity | - common causes are anabolic steroids and green tea extract
177
How does obesity cause high BP
- sleep apnea - renal vessel compression - perivascular adipose tissue
178
Sleep apnea and inc BP
- cardiac press overload due to frequent changes in thoracic pressure - inc cardiac o/p due to hypoxia - inc cardiovascular inflammation
179
Renal vessel compression and HTN
- inc abd pressure due to fat - restricted vessel expansion - impaired naturesis
180
NAFLD
- most common cause chronic liver disease - 45% hispanic - 33% caucasians - 24% blacks - more than 2/3 have obesity - 30% of pts with NAFLD progress to inflammation NASH - leads to cirrhosis and inc risk for HCC
181
Medications that can inc NAFLD
- steroids - HAART - amiodarone - tamoxifen - methotrexate
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2/2 NAFLD
- excessive, rapid weight loss - starvation - TPN - hep C infection - environmental toxicity - wilsons dz - celiac dz - lipodystrophy - disorders of lipid metabolism
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Tx NAFLD
- weight loss and diet | - no meds approved, but metformin, GLP1 agonists, and vit E may help
184
How obesity causes CA
- release of cytokines - inc CA promoting hormones - inc insulin, ILGF-1 which stimulate tumor growth - adipose tiss hypoxia due to inc growth and press leads to angiogenesis
185
Cytokine cause of CA
- damages DNA - promotes gene mutations - enhance angiogenesis - promotes proliferation - increases ROS - cytokines cause endothelial dysfunction
186
Obesity and CA prevalence
- 2nd most common preventable cause of cancer - soon may become #1 - causes 5-10% of CA - increasing cause of cancer in young adults
187
Causes reactive oxygen species
- obesity, adiposopathy, smoking, and dec expenditure - makes imbalance that body can't clear - damage DNA and contribute to CA - contributes to aging
188
foods helpful anti-oxidants
- apples, cherries, grapes, grapefruit - tomatoes, squash - berries - crufiferous and green leafy veggies - legumes - nuts - high fiber whole grains - some coffees and teas
189
Candidates for bariatric surgery
- BMI >/= 40 - BMI >-= 35 with co-morbidities - potential in future for BMI >30 with complications
190
Bariatric pre-op evaluation
- medical evaluation - mental health - nutritional assessment - educational support
191
Roux-en-Y stats
- best improvement in metabolic dz over sleeve - inc risk of malabsorptive complications - wt loss 60-75% - better for higher BMI, GERD, DM2
192
Sleeve stats
- improves metabolic dz - nutrient deficiencies are uncommon - no long term data - wt loss 50-70% - good for those with metabolic dz
193
lap band stats
- least invasive - 25-40% need removed - wt loss 30-50% - better for lower BMI without metabolic synd
194
Biliopancreatic diversion with duodenal switch stats
- greatest amt wt loss and resolution of disease - inc risk deficiencies - wt loss 70-80% - best for higher BMI, DM2 - most technically challenging
195
Other FDA approved bariatric techniques
- Aspiration therapy with modified PEG - Vagal n blocking - intragastric balloons - endoscopic plication devies
196
Aspiration therapy with modified PEG
- removes 30% of ingested meal - use if BMI 35-55 - lose 12% in 1 yr
197
Vagal n blocking
- decreases hunger and inc satiety - use if BMI >40 or >35 with co-morbidities - cause 8.5% wt loss
198
intragastric balloons
- inserted into stomach and filled - Use if BMI >30 and <40 - approved for 6 mth use - cause 12-31% wt loss - can cause blockage, N/V, ulcer, gastric hypertrophy
199
Endoscopic plication devices
- sutures the stomach smaller without removal, done endoscopically - cause 30-50% wt loss - currently in investigation phases
200
Early complications bariatric surgery
- leak or perforation - Bleeding - Wound infection - Gastro-gastric fistula - Band erosion - incisional hernia - internal hernia - intestinal obstructin - stricture - band obstruction - dumping syndrome - GB dz - marginal ulcer - micronutrient deficiences
201
Leak and perforation
- more after complicated procedures - cause acute peritonitis - NL in 72 hrs to 14 days - F/C, tachy, abd pain, WBC - need urgent surgical management - use water soluble contrast if able - imaging not always diagnostic
202
Bleeding after bariatric surgery
- at surgery site or GI bleed - NL in 72 hrs - may need reoperation - tachy, hypotension, dec H&H, oliguria - after 3 days is more likely due to erosions or ulcerations at anastomoses and stable lines
203
Gastro-gastric fistula
- Causes inc capacity to ingest food an/or inc passing of food into gastric remnant - may cause suboptimal wt loss and recurrent of metabolic dz - non-healing ulcer should raise concer
204
Band erosion
- suspect if band full, but pt doesn't feel restriction - can present with infection and pain - diagnose with EGD, need removal of band
205
Incisional hernia
- more with open procedures - may need CT/us to confirm - repair normally post-poned until after wt loss
206
internal hernia
- intermittent, post-prandial pain and emesis - due to herniation th/ defect in mesentery - need surgical correction
207
Intestinal obstruction
- usually 6 mths or longer from surgery | - due to internal hernia, scarring, narrowing of limb, intussusception, or adhesions
208
stricture
- post-prandial epigastric abd pain and V - usually 4-6 wks following RNY - may be due to narrowing of anastomoses regions - tx with EGD +/- balloon dilation
209
Dumping syndrome
- more in RNY - common in first 18 mths - occurs in 70-85% - facial flushing, lightheaded, fatigue, hypoglycemia, post-prandial diarrhea - avoid high glycemic foods, avoid fluids with meals
210
Marginal ulcer
- occurs at anastomosis site, most in RNY - PPI tid and carafate - opitmize protein - surgery if not heal
211
RNY micronutrient defiencies
- B1 - B9 - B12 - D - Ca - Fe
212
Sleeve micronutrient deficiences
- B1 - B9 - B12 - D
213
LAGB micronutrient deficiences
- B1 | - B12
214
BPD micronutrient deficienes
- A - B1 - B9 - B12 - D - E - K - Ca - Fe - Zn - Cu
215
How to eat after bariatric surgery
- start with 3-5 small meals per day - limit liquids until 30 min after meal - chew thoroughly - protein 60g/d (1.2-1.5g/kg/d) - avoid concentrated sweets
216
Vitamin supplementation post-op
- bariatric MTV - B12 500 mcg/d or 1000 mcg/m IM - iron 27 mg daily with 500 mg vit C - Ca citrate 1200 mg/d with Vit D3
217
Vit A replacement
If corneal keratinization and ulceration- 50-100,000 IU IM x3d, then daily for 2 weeks If no corneal changes- 10,000-25,000 IU po for 1-2 wks
218
Vit A supplement
If on-going losses | - 5000 IU/day
219
Vit B1 replacement
If hyperemesis: | - 100 mg IV x7d, then 50 mg/d until normal
220
Vit B1 (thiamine) maintenance supplement
3 mg per day
221
Vit B9 (folate) replacement
- cont supplement with 400 mcg | - add 800 mcg/d po until in normal range
222
Vit B9 (folate) supplement
If issues with deficiency should have at least 500 mcg/d
223
Vit B12 (cobalamin) replacement
Until in normal range: - 1000 mcg/month IM - 1000 mcg/wk sublingual - 350-500 mcg/d oral
224
Vit B12 supplement
500-1000 mcg po daily or do monthly injection 1000 mcg
225
Calcium replacement
- ensure adequate vit D - Calcium citrate 1200-1500 mg/d - citrate better absorbed than carbonate - take 1 hr apart from other supplements, especially iron
226
Vitamin D replacement
50,000 U weekly until in normal range | - then D3 3,000 U if still substantial malabsorption
227
Vit D supplement
Once normal, maintain on: - D3 1,000 U after gastric bypass - D3 2,000 U after BPD/DS
228
Vit D3
cholecalciferol | - prefered over D2 due to longer 1/2 life and more potent
229
Vit D2
ergocalciferol | - dietary vit D found in plants
230
Vit E replacement
400-800 IU/d po
231
Zinc replacement
60 mg elemental Zn bid | - Zn inhibits copper absorption, so need 1 mg Cu for every 10 mg Zn given
232
Zinc supplement
- if continued malabsorption, then 30 mg/d | - if less risk, then 8-15 mg/d
233
microbiom
collection of micro-organisms
234
microbiotia
organisms themselves
235
function gut microflora
- metabolize essential nutrients - synthesize vit K - fermenting sugars - digest cellulose - promote angiogenesis - enhancing enteric n function
236
bariatric surgery changes to microbiome
- dec availability of nutrients to gut - dec lipogenic signaling - dec inflammation - dec extraction of calories from carbs - alter gut hormones
237
Obesity prevalence
2015-2016 40% of adults and 18.5% youth - AA and hispanic more affected - Asians least
238
Melanocortin 4 receptor deficiecy
- obesity - hyperphagia starting in early childhood - insulin resistance - inc bone mineral density - accelerated linear growth - dec sympathetic nervous system activity
239
Melanocortin 4 rec def genetic abnormality
- AD or AR - most common genetic defect causing obesity - polymorphism of gene on chrom 18q22
240
prader-willi syndrome
- obesity - hyperphagia - short stature - poor growth - weak m tone - small hand/feet - developmental delay - underdeveloped genitals - mild/mod MR - narrow forehead - triangle mouth - almond eyes - fair skin, light hair
241
prader-will genetic abnormality
- not inherited - loss of function mutation chrom 15 - most common human obesity syndrome
242
Albright's hereditary osteodystrophy
- obesity - short stature - round face - skeletal defects (shortened metacarpals and metatarsals) - dental hypoplasia - soft tissue calcifications - pseudohypoparathroidism
243
Albright's hereditary osteodystrophy genetic abnormality
- assoc with defect gene GNAS1
244
Bardet-Biedl Syndrome
- obesity - HTN, DM, HLD - blindness (retinal dystrophy and pigmentary retinopathy) - anosmia - hearing loss - dysmorphic extremities - poor coordination - dental abn - intellectual disability - beh/emotional issues - hypogonadism - renal cystic dz, renal insufficiency
245
Bardet-Biedl syndrome genetic abnormality
- AR - mutation in at least 16 genes involved in cilia - leads to abn cell movement, chemical signaling, and sensory input
246
cohen syndrome
- obesity - DD - MR - small head - narrow hands and feet - weak tone - retinal dystrophy - joint hypermobility - thick hair, eyebrows, and lashes - open mouth expression - leukopenia - overly friendly
247
cohen syndrome genetic abnormality
- AR | - mutation VPS13B
248
Borjeson-Forssman-Lehman Syndrome
- mostly males - MR - Seizures - large earlobes - short toes - small genitalia - gynecomastia
249
Borjeson-Forssman-Lehman syndrome genetic abnormality
- X-linked | - mutation Zn finger gene PHF6
250
lipodystrophy
- congenital or acquired limitation in the proliferation and differentiation of fat cells
251
Lipodystrophy characteristics
- hyperphagia - muscular appearance due to lack of fat - leptin levels dec - insulin resistance - Hypertriglyceridemia - hepatic steatosis
252
Familial partial lipodystrophy (FPLD)
- 3 types - leptin levels dec - DM - hypertriglyceridemia - tx- nutrition, exercise, metreleptin, bypass
253
FPLD type 1
- mostly women - lipodystrophy arms, legs, breasts - inc central obesity
254
FPLD type 2
- lipodystrophy arms, legs, buttocks, abd, and chest - inc fat back, face, and chin - cushingoid appearance
255
FPLD type 3
similar to type 2
256
Metreleptin
- SC injection - leptin analog - used to tx leptin deficiency and generalized lipodystrophy - men 2.5 mg daily (inc by 1.25-2.5/day with max of 10) - women 5 mg daily (inc by 1.25-2.5/day with max 10)
257
metreleptin drug interactions
- affects CYP p450 | - renally cleared
258
SE metreleptin
- HA - hypoglycemia - dec wt - abd pain - warning if T cell lymphoma, autoimmune dz, and hypersensitivity
259
Diagnostic questionnaires for OSA
- Berlin sleep questionnaire - epworth sleepiness scale - STOP-BANG
260
STOP-BANG
Snoring Tiredness Observed apnea high blood Pressure ``` BMI >35 Age >50 Neck >40 cm Gender male 1 pt for each and 3 pts is high risk ```
261
Sleep lab diagnosis of OSA
Done by AHI (apnea hypopnea index) - mild 5-15/hr - mod 15-30 - sev >30
262
Consequences of untreated OSA
- worsening obesity - CHF - Afib - Nocturnal dysrhythmias - CVA - HTN - DM2 - Pulm HTN
263
Peripheral SQ adipose tissue (SAT)
- does have some protective effects, however, when too much is pathogenic - leads to overflow into other organs and inc risk metabolic dz - 80% of total fat mass - most of adipose derived FFA come from SAT - inc in abd SAT inc risk for metabolic dz and CVD, though VAT is higher
264
Visceral adipose tissue (VAT)
- high lipolysis than SAT - dec sensitivity to insulin - more associated with metabolic dz and CVD than SAT - surrogate marker for global fat dysfunction
265
benign multiple symmetrical lipomatosis
- inc fat in SQ areas of arms, legs, shoulders, and neck - inc sec anti-inflammatory adipokines - not normally develop endocrine or lipid disorders
266
Metabolically healthy but obese (MHO) phenotype
- prevalence varies widely based on criteria - higher rates of heart dz and CHF - still experience fat mass dz - 30-40% will dev metabolic dz within 6 yrs
267
Metabolically obese normal weight (MONW) phenotype
- may have genetic or acquired dysfunction of other body organs leading to abn metabolic function of adipose tissue
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Why asians have inc metabolic dz and lower BMI
- larger adipocyte size - dec adipocyte number - inc android fat distribution and visceral fat distribution - inc FFA and leptin - inc pro-inflam factors - inc insulin resistance
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Stress and obesity
- prolonged stress response increased blood cortisol and glucose - promotes unhealthy eating behaviors
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gourmand syndrome
occurs with damage to R frontal lobe (trauma or CVA) | - post-injury passion for gourmet foods
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2 compartment body areas
- fat mass - fat free mass - can be evaluated by DXA, underwater weighing, air displacement plethysmography, bioelectrical impedence, skin fold thickness, deuterium dilution
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3 compartment body areas
- fat mass - total body water (lean tissue mass) - fat free dry mass (bone and protein) - DXA can assess all 3 - bioelectrical impedence may also
273
4 compartment body areas
- fat mass - total body water - bone mineral - protein - can be assessed by combining 2 different methods (ie DXA + bioimpedence)
274
6 compartment body areas
- fat mass - total body water - bone mineral - non-bone mineral - protein - glycogen
275
Gold std for body composition
- DXA | - most dependable for measuring body fat, lean mass, and bone density
276
android region on DXA
- area between ribs and pelvis
277
trunk region on DXA
- area between hip joints and lower chin
278
Body composition
- about 60% is water - 75% of m and organs is water - 30% of bone is water
279
DXA assessment of m mass
- doesn't always include clear normals - vary among individuals, gender, age, and PA - %fat lower in AA - % fat higher in hispanic
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Whole body plethysmography
- measures volume by displacement - no exercise 2 hrs prior - no eating or drinking 1 hr prior - light, tight fitting clothing
281
bioelectrical impedance analysis
- accurate - most inexpensive - hydration dependent - electric current flows more easily through water and m than fat - remove all metal prior - use restroom prior - no exercise for 8 hrs - avoid caffeine or alcohol 12 hrs prior - may over or under estimate % fat compared with DXA
282
deuterium dilution
- isotope of hydrogen - mixes with water in the body and eliminated in urine, saliva, and sweat - collect pre and post 3-4 hrs saliva specimen and calculate TBW based on total dose/(saliva pre-baseline post)
283
energy expenditure
amt of energy needed to carry out function - resting metabolic rate (5-10%) - PA (1-2%) - dietary thermogenesis (20%)
284
energy expenditure in mod PA individuals
- 70% resting metabolic rate - 20% PA - 10% dietary thermogenesis
285
NEAT
- non-exercise activity thermogenesis - ie: standing, maintaining posture, stairs, walking, etc - often represents the widest variance in total energy expenditure - improving this can be better than just increased bouts of exercise
286
average steps for Americans
<5000/d
287
activity level based on steps
<5000 sedentary 5000-7500 low active 7500-10,000 mod active >10,000 active
288
Calories burned per steps
approximately 1 cal/20 steps
289
basal metabolic rate
- energy expended while fasting, rested, and supine | - increased with greater body weight
290
resting metabolic rate
- energy expended at rest | - increased with greater weight
291
Resting metabolic rate use
In NL weight: - skeletal m <25% - liver 20% - brain 20% - RMR 40%
292
direct calorimetry
- measures heat generated by organism | - value of generated heat can estimate energy expenditure
293
indirect calorimetry
- estimates basal energy expenditure and resting energy expenditure by O2 consumption and CO2 production
294
direct calorimetry formula
TEE = 60% from heat + 40% from ATP production
295
Weir equation
Indirect calorimetry | - EE = VO2 + VCO2- Nitrogen
296
Respiratory quotient
Indirect calorimetry | - RQ = CO2 production/O2 consumption
297
estimation of resting metabolic rate
- can be calculated based on pt characteristics | - harris-benedict and mifflin St. Jeor equation
298
metformin benefits
- improves insulin resistance, PCOS, fatty liver, CAD - may help reduce CA rate of colon, ovarian, lung, breast, and prostate - may dec appetite through inc GLP-1 and dec peptide YY - improve insulin sensitivity
299
general principles of healthy diet
Avoid: - highly processed foods - sweets, junk foods - energy dense beverages Encourage: - healthy proteins and fats - veggies, fruits, berries - nut, legumes, whole grains - complex carbs over simple - low GI over high GI - high fiber over low fiber - read labels
300
Saturated fats
- carbon chain fatty acids with no double bonds - solid or semisolid at room temp - less likely to become oxidized and rancid - coconut and palm oils have large amounts of - Found in meats, dairy, vegetable oils - can impair endothelial function
301
Polyunsaturated fats
- carbon chain fatty acids with multiple double bonds - liquid at room temp - ie: vegetable and fish oils - include nuts, omega 3s from fish
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monounsaturated fats
- carbon chain fatty acids with one double bond - liquid at room temp - ie: olive and canola oil
303
resistive strength training
- emphasize "core" m exercises - use variety of free weights, machines, and bands - sore m can be normal - sore joints mean poor technique
304
METS
- metabolic equivalent tasks - equal to amt of energy expended during 1 min while lying down to rest - kcal = METS x wt x time - standing = 2 - walking 4 mph = 4 - running 10 mph = 16
305
types of resistance
- arguing - denying - ignoring - interrupting
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ways to roll with resistance
- simple reflection (restate what the patient has said about themself) - shift focus back to most important issues - reframe the concerns the patient has
307
identify discrepancy
- find mismatch between patients today and how they want to be in the future - find contrasts between current behavior and life goals
308
amplify discrepancy
- can help resolve ambivalence | - can facilitate thoughts of change
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resolve ambivalence
- discuss benefits for change, risks of change, and benefit/risk of no change
310
illicit talk of change
- how important is it - what will happen if they don't change - how do actions fit values - how do they plan to change
311
Change metrics
- scale 1-10 rate how important the change is (facilitates talks of benefits) - scale 1-10 rate readiness to change (facilitates talks of stage of readiness) - scale 1-10 rate confidence in ability to change (facilitates talks of barriers)
312
self-efficacy affirmations and feedback
- focus on past successes | - highlight existing strengths
313
OARS of motivational interviewing
- open ended questions - affirmation - reflections - summaries/plan
314
FRAMES of motivational interviewing
- Feedback and personal risk - responsibility of pt - advice to change - menu of strategies - empathetic style - self-efficacy
315
Behavioral therapy
- helps people to reflect on their current behaviors and make strategies to change those behaviors to more positive ones
316
Areas of behavioral therapy
- physiologic - mental stress - timing and emotions - environment - information gap - reward - eating disorders
317
physiologic behavioral area
- biologic forces causing weight gain or preventing loss - hypothalamic dysfunction - 5 senses giving signals to eat - more hunger or lack of satiety
318
lisdexamfetamine dimesylate
used to tx binge eating disorder - CNS stimulant - not indicated for wt loss - schedule II drug - dose in AM to avoid insomnia - start 30 mg qAM x1 wk, then 50 mg x1 wk, then 70 mg max dose - renally dose - interaction with MAOIs causing hypertensive urgency
319
lisdexafetamine SEs
- anorexia - anxiety - dec appetite and wt - diarrhea - dry mouth - irritability - insomnia - nausea - upper abd pain - vomiting - tachycardia - constipation - jittery
320
lisdexafetamine contraindications
- other CNS stimulants - h/o drug abuse - allergic rxn - MAOIs (don't use within 14 days of last dose) - avoid if known CAD, CVA, CHF - uncontrolled HTN - Raynauds, PVD
321
wt loss and neurohormonal changes
Promotes wt gain: - dec leptin, insulin, cholecystokinin, peptide YY which all inc appetite - inc ghrelin which inc appetite - continuous high levels of insulin and leptin lead to resistance which limits appetite reduction when people are obese
322
why people regain weight
- neuro-biologic processes to resist under-nutrition - weak resistance of body to overnutrition - neurohoromonal changes that stimulate appetite - resistance to insulin and leptin - lack of routine maintenance for diet and exercise after - decreased resting energy expenditure - greater m efficiency so less energy expended in PA
323
Stimulus control
- avoid eating for times except with hunger - avoid frequent snacking - avoid binge eating - portion control - remove unwanted foods from environment - be mindful of eating stimuli
324
cognitive restructuring
- address body image issues - reshape negative thoughts which lead to dysfunctional eating - emphasize realistic weight loss expectations
325
Support for weight loss
- stress management - back-up activities to engage in during stressful times - health care team - mental health - social - commercial programs - support groups
326
Technology for weight loss
- apps can help record and assess nutrition and PA - web-sites can give helpful food and PA information, recipes, support, etc - social media for support and tips
327
pharmacotherapy metabolism and obesity
``` Oral administration leads to: Metabolism by GI tract and liver by first pass effect - GI enzyme breakdown - bacterial enzyme breakdown - phase 1 reactions - phase 2 reactions ```
328
phase 1 metabolism of medication
- most by CYP450 system - oxidizes the compound - makes active to inactive drugs or prodrugs into active metabolites - products excreted or undergo further conjugation
329
phase 2 metabolism of medication
- conjugation by glucuronidation, acetylnation, methylation, etc - most however are inactive and are excreted
330
Cell transporters for medications
- many compounds utilize transporters to get across cell membranes or e used for their actions - will bind to proteins to promote longevity and availability
331
hydrophilic drugs
- polar - mainly in circulation, not much in tissue - transported into tissue by transporters - eliminated by kidneys - dose may be based on IBW
332
lipophilic drugs
- non-polar - mainly in body tissue - can cross membranes - dose based on actual BW - stay in tissue longer
333
GFR in obesity
- often have increased GFR | - some estimates are not validated in pts with obesity
334
Phentermine dosing
- phentermine HCl 4-8 mg tid qAC - phentermine resin 15-30 qAM - phentermine HCl 18.5-37.5 qAM - renal excretion, so caution in renal impairment
335
phentermine drug interactions
- MOAIs, none within 14 days - alcohol - may need to reduce insulin or OHMs - adrenergic neuron blocking drugs
336
phentermine equivalent dosing
phentermine HCL 8-37.5 is equivalent to phentermine resin 6.4-30 mg
337
orlistat contraindications
- chronic malabsorption syndrome | - cholestasis
338
contrave drug interactions
- MAOIs - opiates - SSRIs/TCAs caution - anti-psychotics - beta-blockers - digoxin - plavix can inc wellbutrin concentration - carbamazepine, phenobarb, and phenytoin dec wellbutrin - dopaminergic drugs
339
qysmia and OCPs
- may alter exposure to OCPs causing irregular bleeding, but not an increased risk of pregnancy - don't d/c OCPs during use - women should have neg preg test prior and monthly
340
monitoring on qysmia
- pregnancy tests - HR - depression/SI - metabolic acidosis - elevated Cr - possible hypoglycemia
341
dietary fiber for wt loss
Reports of wt loss are inconsistent - inc fullness - delay carb absorption - dec fatty liver - inc insulin sensitivity - SEs bloating, flatus
342
prebiotics for wt loss
some human studies with weight loss, but most rodent models - indigestible oligosaccharides - stimulate intestinal growth to make better microbiome for wt loss - SEs bloating, flatus
343
probiotics for wt loss
some human studies with wt loss, most in rodents - SEs bloating and flatus - help protect against yeast and other bacteria overgrowth
344
caffeine for wt loss
Some minor wt loss - dec appetite - inc fat oxidation
345
green tea for wt loss
Minor wt reduction by meta-analysis - contains caffeine and epicatechin - antioxidant - SEs: caffeine SEs, constipation, indigestion, liver injury
346
green coffee for wt loss
Minor wt loss - less caffeine than black coffee - contains chlorogenic acid
347
Phytoestrogens for obesity
Minor wt loss if used as substitute for higher fat or higher calorie foods - found in soy products - SEs N, bloating, constipation, hormone abn
348
Conjucated linoleic acid (CLA) for obesity
possible short-term minor wt loss - natural trans-fat - promotes lipolysis, thermogenesis, and browning of fat - SEs: N, indigestion, diarrhea, fatigue, fatty liver, insulin resistance, inc cholesterol, inc inflammation
349
Supplements with insufficient data for wt loss
- chitosan - berberine - forskolin - garcinia cambogia - glucomannan - glucosinolates - hoodia gordonil - irvingia gabonensis - raspberry ketones - geranium - ephedra - bitter orange - DNP - PPA - sibutramine
350
Unsuccessful wt loss supplements
- hCG
351
Cardiovascular changes in obesity
- inc HR if inactive - in risk Afib - inc blood volume - inc CO - inc vascular resistance - inc arterial pressure - inc pulm a pressure
352
Heart structure changes in obesity
- myocardial fibrosis and apoptosis - fat deposition in heart (epicardial and myocardial) - inc coronary calcium - LAE - LV and RV hypertrophy
353
Endocrinopathy related to obesity
- activate sympathetic nervous system - activation RAAS - hyperinsulinemia - hyperleptinemia leading to leptin insensitivity
354
heart function change with obesity
- hypoxia - LV diastolic and systolic dysfunction - R heart failure
355
immunopathies with obesity
- inc pro-inflammatory cytokines - inc inflammatory macrophaes, T-cells, mast cells - dec anti-oxidants - inc CRP
356
"Sick" epicardial adipose tissue (EAT) fat
- supplies pro-inflammatory cells and cytokines to vasa vasorum - contribute to dysfunction, fibrosis, and electrical remodeling - excessive FFA oxidation making toxic metabolites - impairs mitochondrial function - leads to myocardial inflammation and dysfunction - vasoconstriction - arterial stiffness - worsening of plaques - weakening of the arterial walls - predispose to plaque rupture
357
action of insulin
- binds to cell and activates MAP and P13K signaling - inc cell growth - cause glycogen, lipid, and protein synthesis - increased NO production and vasodilation
358
macrophages in obesity
- recruited to areas of fat due to adipocyte cell death, hypoxia, inc signaling - M1 macrophages inc in obesity and secrete TNF, IL-6, and MCP-1 pro-proinflammatory - M2 macrophages are predominant in lean and secrete anti-inflammatory factors
359
Adiponectin in obesity
decreased - it is an anti-inflammatory cytokine that helps with insulin sensitization and glucose uptake - leads to inc intra-abdominal fat - inc apoB - inc TG, dec HDL, inc LDL
360
Normal eating and BP
- eating stimulates parasympathetic nerv sys and catabolic sympathetic nerv sys - get inc blood flow to splanchnic vessels and inc vasodilation - can lead to dec BP and hypotension - get inc HR
361
Lipids in adipocytes
- cholesterol is a small fraction of lipids in adipocytes - majority are TG - HDL scavengers bring cholesterol to the fat cells
362
TNF
- pro-inflammatory cytokine - impair FFA uptake by adipose tissue - impairs adipogenesis - promotes lipolysis - dec insulin sensitivity - increased in obesity
363
IL-6
Inc in obesity - pro-inflammatory - promote adipocyte lipolysis - inc TG synthesis - dec apo A1 - dec HDL, inc LDL
364
lipoprotein lipase
- found on surface of capillaries - inc in obesity - get inadequate hydrolysis of TG, so inc TG levels
365
cholesteryl ester transfer protein (CETP)
- facilitates exchange of TG and cholesteryl esters - inc in obesity - get dec HDL and small dense LDL
366
Testosterone and cholesterol
- inc LDL - dec TG - dec HDL
367
Estrogen and cholesterol
- dec LDL - inc TG - inc HDL
368
Affect of excess FFA
- Inc deposition in liver--> steatosis - inc liver secretion of VLDL--> hypertriglyceridemia - inc LDL and VLDL remnants - inc renal clearance of HDL--> low HDL
369
Fat deposition and liver disease
- get accumulation of FA, cholesterol, and toxic lipids - makes ROS that lead to mitochondrial dysfunction and hepatocyte death - promotes more pro-inflammatory response - get hepatitis then continued inflammation leads to scarring and fibrosis
370
fatty liver dx
- inc ALT >AST - can have normal LFTs though - u/s can miss NAFLD with liver fat <20% - fibroscan can detect mild changes - CT - MRI- specialized to look at fat is most accurate
371
hepatic fibrosis tools
- NAFLD fibrosis score - fibrosis 4 calculator - serum biomarkers
372
hepatic fibrosis imaging
- transient elastography - MRE - shear wave elastography
373
hepatic fibrosis dx gold standard
- biopsy
374
Obesity and cancer formation
- cytokines damage DNA - promote cell mutations - promote angiogenesis and cell proliferation - mitochondrial stress - release of ROS - promote endothelial dysfunction - insulin gives growth factors to cancer cells - promotes cancer promoting hormones
375
food intake and cancer production
- high intake processed meats (bacon, sausage, lunch meat, hot dogs) - more smoke from grilling
376
foods components beneficial in cancer
- phytochemicals - fiber - antioxidants
377
foods good for cancer
- apples - cherries - citrus fruits - berries - green leafy veggies - carrots - garlic - legumes - nuts - whole grains - coffee and tea
378
anti-obesity drugs in development
- GLP1 agonists (mono and combined with GIP and PYY) - oxyntomodulin agents - Peptide YY agents - neuropeptide Y antagonist - melanocortin-4 rec agonist - ghrelin O-acyltansferase inhibitor - triple monoamine uptake inhibitor - macrophage inhibitory cytokine 1 agonist - leptin analogues - zonisamide-buproprion - SGLT2 inhibitors - amylin mimetics - amylin/calcitonin rec agonists - lipase inhitoris
379
GLP-1 pathwasy
Food goes into system and causes: - inc release GLP-1 and GIP - GLP-1 inactivated to DPP-4 (GLP-1 agonists help to resist degradation) - acts on brain to dec appetite and inc satiety - acts on pancreas to dec glucagon and inc insulin - acts on stomach to dec gastric emptying and inc nausea - acts on fat tissue to dec fat mass and improve adipose function - insulin and glucagon acts on m to inc glucose uptake - glucagon and insulin act on liver to dec glucose production
380
oxyntomodulin agent pathway
released by L-cells in the ileum and colon: - activates GLP-1 receptors - activates glucagon rec - gluc raising of glucagon counteracted by gluc lowering of GLP-1 for net dec in glucose levels - act on brain to dec appetite and inc satiety - act on pancreas to inc insulin - act on stomach to dec gastric emptying, dec ghrelin, and inc N/V - act on fat to dec fat mass, inc lipolysis and inc adiponectin - cause inc uptake glucose in m and dec prod in liver
381
peptide YY pathway
Released by L-cells in ileum and colon - structurally similar to NPY and PP - circulate in 1-36 and 3-36 form - inhibti NPY neurons - act on brain to dec appetite and inc satiety - act on pancrease to inc insulin, dec proliferation of beta cells, and dec apoptosis of beta cells - act on stomach to dec gastric emptying and inc N/V - act on fat to dec fat mass - inc glucose uptake in m and dec gluc production in liver
382
neuropeptide YY (NPYY) pathway
Made in response to fasting - orexigenic - most abundant peptide in CNS - act on brain to inc appetite, dec stress/anxiety and pain - act on SNS to inc vasoconstriction - act on fat to promote fat storage
383
SGLT-2 inhibitor pathway
- dec proximal renal tubule glucose reabsorption - dec GI gluc absorption - dec body wt and glucose levels - doesn't cause inc in insulin, so go into fasting/starvation ketone state - inc FFA to liver to make ketones - restrictive carb diet with this may worsen ketoacidosis
384
early tx for obesity
- try to do interventions early to prevent sick fat disease
385
delayed tx for obesity
- tell person to diet and exercise, but not really engage them fully and tx until after sick fat disease occurs
386
GI hormone regulation of caloric balance before eating
Before eating, hormones inc hunger: - ghrelin - neuropeptide YY
387
GI hormone after eating dec hunger and inc satiety
After eating, horm dec hunger and promote satiety: - somatostatin - cholecystokinin - motlin - insulin - glucagon - pancreatic polypeptide - amylin - fibroblast growth factor 19 - GLP-1 - oxyntomodulin - peptide YY
388
GI horm after eating promote digestion
After eating, horm help with digestion and slow gastric emptying: - cholecystokinin - amylin - GLP-1 - oxyntomodulin - PYY
389
GI horm after eating stimulate digestive enzymes
- gastrin - cholecystokinin - secretin
390
GI horm after eating impairing digestive enzy release
- somatostatin - secretin - PP - GLP-2 - oxyntomodulin - PYY
391
GI horm after eating assist with nutrient management
- somatostatin - insulin - glucagon - fibroblast growth factor 19
392
Absorption in stomach
- water | - alcohol
393
absorption in duodenum
- fatty acids - AA - minerals (calcium, iron) - some vitamins
394
absorption in jejunum
- simple sugars - fatty acids - protein - minerals - vitamin
395
absorption in ileum
- bile salts - bile acids - vit B12 - some vitamins and minerals
396
absorption in LI
- water - NaCl - K - intestinally derived vit K
397
Questions when considering bariatric surgery
- BMI and co-morbidities to qualify - reasonable attempt to lose weight unsuccessful - evaluation by physician and psychologist - commitment to following post-surgery recommendations - specific insurance requirements
398
surgery requirements
- BMI >40 - BMI >35 with co-morbidities - BMI >30 with co-morbidities may becoming classification
399
bariatric surgery pre-op eval
- medical eval - surgical consultation - cardio/pulm/GI consult if necessary - mental health assessment - nutritional assessment - educational support
400
roux-en-Y procedure
- stomach divided into small proximal pouch - then bypasses rest of stomach, duodenum, and portion small intestine - prox stomach added to limb of SI
401
roux-en-Y recovery
- hospital stay 1-4 days | - recovery 1-2 weeks
402
contraindication roux-en-Y
- poor surgical candidate - sev psych - pregnancy - drug or alcohol addiction - untreated gastric ulcer - crohn's disease
403
Common acute complications roux-en-Y
- N/V - dehydration - GI obstruction - GI bleed - acute gout exacerbation - anastomotic leak - infection - cardiac dyshythmia - atelectasis/PNA - DVT/PE - death
404
Common chronic complications roux-en-Y
- wt regain - pouch dilation - anastomotic/marginal ulcers - dumping syndrome - esophageal dilation - SBO - anastomotic stenosis/stricture - gallstones - kidney stones - 2dary hyperparathyroidisi - depression - osteoporosis - gout - bacterial overgrowth - metabolic acidosis
405
Common nutritional issues roux-en-Y
- calcium def - iron def - protein malnutrition - def vit A, C, D, E, B, K, folate, Zn, Mg, thiamine - neuropathies from def
406
vertical sleeve recovery
- hospital 1-2 days | - recovery 1-2 weeks
407
vertical sleeve contraindications
- poor surgery candidate - sev psych - pregnancy - drug or alcohol addiction - untreated gastric ulcer - barrett's - achalasia - prev gastrectomy - prev gastric bypass
408
Common acute complications VSG
- N/V - dehydration - GI obstruction or bleeding - staple line leaks - GERD - cardiac dysrhythmias - atelectasis/PNA - DVT/PE - death
409
common chronic complications VSG
- wt regain - sleeve dilation - worsening GERD, de novo GERD - stenosis/stricture - staple line ulcers and leaks - fistula formation - gallstones - kidney stones - depression
410
Common nutritional def VSG
- Ca - iron - anemia - B12 and B1 - protein malnutrition - vitamin def are uncommon
411
BPD with DS recovery
- hospital stay 2-4 days | - recovery 2-4 wks
412
BPD with DS contraindications
- poor surgery candidate - sev psych - pregnancy - addiction - untreated gastric ulcer - crohn's dz - IBS
413
BPD with DS acute complications
- N/V, dehydration - obstruction - GIB - acute gout - anastomotic leak - infection - dysrhythmia - PNA - VTE - death
414
BPD with DS chronic complications
- wt regain - pouch dilation - anastomotic ulcers - SBO - gallstones - bacterial overgrowth - kidney stones - acidosis - osteoporosis - depression
415
BPD with DS nutritional def
- Ca - hyperparathyroidism - iron - protein - vit A, C, D, E, B, K - folate, Zn, Mg, thiamine - anemia - neuropathy
416
aspiration therapy
Done by PEG tube - drains 30% ingested meal - 12% wt loss in 1 yr
417
electrical vagal blocking system
- pacemaker like implant under skin - blocks vagal impulses causing dec hunger and inc satiety - 8.5% wt loss - can cause gastroparesis
418
intragastric balloons
- indicated for BMI >30 and <40 - approved for up to 6 mths then needs removed - fluid filled of gas filled - 12-31% wt loss in 6 mths - may cause blockage, V, ulcers, gastric hypertrophy, or uncomfortable fullness
419
endoscopic plication
- endoscopic suturing of stomach - investigational - 30-50% wt loss in 1-2 yrs
420
leak or perforation symptoms
- cause peritonitis - most in first 72 hrs post-op - can be any time due to ulcer perforation - acute, severe abd pain, back pain - signs of infection - needs urgent surgery - use water soluble contrast with imaging, but imaging may be negative
421
bleeding post-op
- most in first 72 hrs - tachycardia, hypotension, dec H&H - after 1 week more likely due to erosion and ulceration
422
gastro-gastric fistula
- more with RNY - have increased ability to eat food - may lead to wt gain - be concerned for if have non-healing ulcer
423
band erosion
- suspect if band full but pt not feel restriction - can present with infection - diagnose with EGD - need surgery
424
internal hernias
- more with RNY and BPD/DS - intermittent, post-prandial pain and emesis - get hernia through defect in mesentery - surgical emergency if sudden onset
425
stricture
- most 4-6 wks from RNY - may be associated with anastomic ulcer - occurs at areas of anastomosis - repair with EGD +/- balloon dilation - surgery if refractory
426
dumbing syndrome
- after RNY - due to bypass of pyloric mechanism - occurs in 70-85% - facial flushing, lightheaded, fatigue, hypoglycemia, and post-prandial diarrhea - avoid high glycemic foods and avoid liquids with meals
427
risks for ulcerations
- NSAIDs - steroids - nicotine - alcohol - drugs - caffeine
428
Common nutritional def post-op RNY
- B1, B9, B12, D, Ca, Fe
429
Common nutritional def post-op Sleeve
- B1, B9, B12, D, Fe
430
Common nutritional def post-op LAGB
- B1, D
431
Common nutritional def post-op BPD
- A, B1, B9, B12, D, E, K, Ca, Fe, Zn, Cu
432
Vit A def
- fat soluble nutrient - involved in lipid and glucose metabolism - night blindness - monitor retinol levels after BPD/DS
433
B1 (thiamine) def
- water soluble nutrient - involved in fatty acid oxidation - cause beriberi - dry beriberi- Wernicke-korsakoff encephalopathy - wet beriberi- CHF - alcoholics at risk - more common in AA and hispanics post-op - can be after all surgeries - inc risk with post-op vomiting - may have weakness, anorexia, constipation, V
434
Wernicke-korsakoff encephalopathy
- dementia - ophthalmoplegia - ataxia - amnesia
435
Vit B2 (riboflavin) def
- water soluble nutrient - bright pink tongue - cracked lips - throat swelling - scleral erythema - dec blood count - coma/death - rare complication - usually only check if signs of deficiency
436
vit B3 (niacin) def
- water soluble nutrient - develop pellagra (diarrhea, dermatitis, dementia) - dermatitis mostly in sun-exposed areas - rare complication - usually only check if signs of deficiency
437
Vit B5 (pantothenic acid ) def
- essential water soluble nutrient - used to make coenzyme A, prot, carbs, and fat - found in most foods - causes wide range of symptoms - rarely seen
438
Vit B6 (pyridoxine) def
- essential water soluble nutrient - used for neuro function - skin eruptions- seborrheic dermatitis, intertrigo - atrophic glossitis - angular cheilitis - conjunctivitis - sideroblastic anemia - somnolence/confusion/neuropahy - rare complication - only check if symptoms
439
Vit B7 (biotin) def
- essential water soluble nutrient - used in FA and AA synthesis, and gluconeogenesis - made by intestinal bacteria - hair loss - conjunctivitis - erythematous rash around eyes, nose, mouth, and genitals - anemia - CNS/PNS disorders - rare - check if signs
440
Vit B9 (folate) def
- essential water soluble nutrient - megaloblastic (macrocytic) anemia - dec appetite, wt loss - relatively common in all - routinely monitor - provide post-op supplementation
441
vit B12 (cyanocobalamin) def
- essential water soluble nutrient - absorbed by intrisic factor (IF) in terminal ileum - megaloblastic (macrocytic) anemia - neuropathy - common after all - routinely monitored - routine supplementation
442
vit c def
- essential water soluble nutrient - cause scurvy - lethargy, wt loss - dry hair and skin - bleeding gums, tooth loss - F, death - rare - check if signs
443
vit D def
- essential fat soluble nutrient - used in calcium metabolism, bone heath, and fat - cause osteopenia, osteoporosis, hypoCa, secondary hyperparathyroidism - common - lower in AA - routine supplementation - routine monitoring with 25-OH vit D, Ca, PTH
444
vit E def
- essential fat soluble nutrient - used in antioxidant and enzym functions, gene expression, and neuro function - cause neuropathy and ataxia - rare - more often after BPD/DS - alpha-tocopherol levels routinely monitored after BPD/DS
445
vit K def
- essential fat soluble nutrient - used in coagulation - cause easy bruising and bleeding - rare - more common after BPD/DS - PT routinely measured after BPD/DS
446
micronutrients definition
- chemical substances in food which we need only small amount for growth and function
447
phytochemical definition
- bioactive compounds in plants - def lead to organ/tissue dysfunction - help with oxidative stress
448
minerals definition
- non-organic substances needed to function | - Ca, Ph, Mg, K, Na
449
trace elements definition
- non-organic substances needed for body functions | - Fe, Cobalt, Zn, selenium, iodine, molybdenum
450
Ca def
- essential mineral - help with nervous sys, m contraction, bone - Mg def may worsen Ca def - cause osteoporosis, m tetany/spasm, paresthesia, secondary hyperparathyroidism - common after all except band - routinely monitor and supplement
451
Copper def
- trace element - may accompany iron def - get anemia, neuropathy, ataxia, inc m tone/spasm, cardiomegaly - rare - check if symptoms
452
Iron def
- trace element - microcytic anemia, pica - common - monitor iron, ferritin, transferrin, and total IBC - routinely supplement - don't take with calcium
453
selenium def
- trace element - protects from free radicals - cause keshan dz (cardiomyopathy) - rare - check if symptoms
454
zinc def
- trace element - help with intestine mucosa function - cause poor wound healing - hair loss - acrodermatitis enteropathica rash - taste alterations - glossitis - impaired folate absorption - common, more with BPD/DS - monitor if signs
455
eating principles after bariatric surgery
- 3-5 small meals - dec meals as portions inc - chew thoroughly - avoid liquids with meals - 60g/day prot (1.2-1.5 g/kd/d lean mass) - avoid concentrated sweets - take MTV
456
supplements after bariatric surgery
- MTV - B12 500 mcg/d tab or sublingual or 1000 mcg/mth IM - iron 27 mg elemental iron with 500 mg vit C - Ca 1200 mg/d with vit D3
457
function of gut flora
- metabolize essential nutrients - ferment sugars - digest cellulose - promote angiogenesis - inc enteric n function
458
common gut flora
most in ileum and colon - G neg bacteroides - G pos firmicutes
459
gut flora in obese
get increased firmicutes which increased calories absorbed
460
gut flora promotion of inc body fat
- inc nutrient absorption - inc lipogenesis - inc inflammation - alterations in bile acid metabolism - alterations gut hormones
461
changes in biotia after surgery
- dec availability of nutrient delivery - dec lipogenic signaling - dec inflammation - alter bile-acid metabolism - dec firmicutes
462
% obese/overeright in US
70% | - extreme obesity 7%
463
obesity in 3rd world countries
- still see malnutrition | - also having issues with obesity rise
464
reason for increased obesity
o Decreased temp variability in surroundings o Dec length of sleep o Intestinal bacterial changes o Medications o Older maternal age o Fertility treatments o Hypothalamic injury from calorie overload leads to resistance to leptin and shift up in “weight setpoint”
465
survival and BMI
o BMI 30-35 survival decreased by 2-4 yrs o BMI 40-45 survival decreased by 8-10 yrs o Abdominal obesity has higher risk for cardiovascular risk and all-cause mortality
466
predictor of obesity in infants
- BW not as much a factor | - growth rate more influential
467
types of fat
- white - brown - beige
468
white fat
- release FA - TG storage - more energy storage - chronic cold exposure helps to become beige/brown
469
brown fat
- produces heat - burns FA and glucose - activating brown fat inc blood flow, cardiac output, and metabolic output
470
beige fat
- can develop into brown fat
471
Different levels of bias
- structural - interpersonal - intrapersonal
472
types structural bias
- see in advertising | - requirements for wt loss surgery, industry standars
473
types interpersonal bias
- like structural - media - personal views about others
474
intrapersonal bias
- bias against yourself
475
bias towards obesity
- viewed more negatively than other minority groups - even in those treating obesity - people who have lost weight on own tend to be more critical and less compassionate.
476
how to talk about obesity
- ask permission - open-ended questions - focus on behaviors and successes, not just weight - focus on health - realistic expectations - make changes for whole family
477
amount of people who regain weight
75-80% in 2 yrs
478
Wt loss and set-pt
- the more weight we gain, the higher our set point and what our body defends - when lose wt, need to restrict even more to maintain that wt as opposed to naturally thin people - metabolism dec to try to burn less calories - doesn't change even if maintain that wt for years
479
interventions to help maintain wt loss
- resistance training (helps dec m efficiency and burn more calories)
480
crown like structure in fat tissue
- macrophages and T-cells around single adipocyte | - higher amts linked to worse vascular outcomes
481
% wt loss and health outcomes
- 5% wt loss can improve glycemic control | - >10% needed to improve inflammation and metabolic function
482
obesity and addiction to food
- get down regulation of dopamine due to chronic exposure | - may cause inc over-eating to compensate for the dec reward pathway
483
Edmonton obesity staging system (EOSS)
- puts patient in stages 0-4 | - based on medical, mental, and functional complications
484
stopping qysmia
- need to taper off higher doses due to topamax
485
realistic wt loss goals
- up to 2 lb/wk | - up to 10% baseline TBW
486
maintaining wt
- after wt loss, still need to restrict calories and inc activity to maintain - recommend >250 min/wk mod intensity exercise - want to dec calories, but inc quality (low energy dense foods)
487
Calorie reduction for wt loss
- females 1200-1500 kcal/d - males 1500-1800 kcal/day - dec total intake by 500-750 kcal/d
488
CBT in wt loss
- combining CBT with dietary and lifestyle changes most helpful
489
alternate day fasting
- alternate 25% of calories and 125% calories
490
time restricted eating only in evening
- if restricct eating to evening, actually worse - worse glucose, insulin, BP, and lipids - still get wt loss though
491
food eating pattern in meal
- eating veggies and prot rich foods first dec glycemic load and lower post-prandial gluc and insulin
492
post-op lab f/u roux-en-Y
- labs every 3-6 months for 1st yr, then annually - CBC, CMP, iron studies, B12, lipids, 25-OH vit D - consider PTH, thiamine, and folate
493
post-op lab f/u BPD/DS
- every 3 months for 1st yr, then every 3-6 mths | - CBC, CMP, iron studies, B12, lipids, albumin/prealb, folate, A, D, E, K, INR, PTH, Zn, Se,
494
% children with obesity
- 18% have obesity
495
asking about food insecurity
- in past 12 mths did you worry about if food would run out before you got more - in past 12 months did the food run out and couldn't afford to buy more - refer + screen to community resources
496
pediatric modifiable factors to prevent obesity
- rate of wt gain in infancy - infant feeding (breast, bottle, intro solids) - diet quality - parent feeding practices - routines - sleep and PA - TV time - no sugar
497
good food habits for pediatric obesity prevention
- follow feeding cues - food introduction at 6 mths or later - breast instead of bottle - allow self-feeding - no fast food
498
normal infant wt gain
- triple wt by 1 yr | - triple wt again at 9.5 yrs
499
Ellyn Satter Method for peds feeding
- parents decide what, when, and where child eats | - child decides how much to each and if they want to eat
500
3 day eating cycle toddler
- day 1 eat great - day 2 graze - day 3 not eat much
501
normal BMI pattern in kids
- nadir in BMI around 4-6 yrs b/c more ht than wt gain | - For younger children wt for length chart more helpful
502
high risk BMI pattern in kids
- early nadir around 3-4 yrs - then inc wt - higher risk obesity in the future
503
very high risk BMI pattern in kids
- never get nadir at 4-6 yrs, just continues to go up | - try to intervene early when don't see nadir to prevent obesity
504
wt loss goals for kids
- nutrition make 2 goals (1 addition, 1 take away) | - 1 activity goal
505
medicare billing for wt loss visits
- have to record 5As - covers up to 22 visits in 12 mths - 1 every wk for 1 mth - 1 every wk for mth 2-6 - 1 every mnth for mth 7-12 - have to show 3 kg wt loss after 6 mths to continue to bill and reassess 5As - G0447 with BMI code
506
BEAM box approach to wt loss counseling
- Behavior (stress/emotions) - Eating - Activity - Medical
507
ACEs and obesity
- 2 or more ACEs inc risk of chronic medical problems and metabolic dz
508
stress and obesity
- worse if unpredictable, more intense, prolonged, and repetitive
509
meds and bariatric surgery in adolescents
- if BMI >95% and co-morbidities unsuccessful with others | - if BMI >99% unsuccessful
510
indications for bariatric surgery adolescents
- DM2 - OSA - NAFLD/NASH - IIH - cardiovascular risks
511
relative indications for bariatric surgery in adolescents
- blount's dz - SCFE - GERD - dec QoL
512
insurance requirements for adolescent bariatric surgery
- most need 95% growth done prior to surgery
513
surgeries performed in adolescents
- gastric band - gastric sleeve - sometimes roux-en-Y - gastric plication may be in future
514
tx of thyroid for weight
doesn't really help
515
screening labs in obesity
- glucose - lipids - LFTs - TSH - A1c - +/- CRP - vit D - consider baseline EKG (for starting meds)
516
BMI indications for meds
- BMI >30 | - >27 with co-morbidities
517
additive effects of meds on wt loss
- activity and diet give certain wt loss - meds give additional wt loss - each med is additive
518
when okay to get pregnant after meds
- 1 mth after stop
519
contrave SEs
- HA common - more SEs if faster titration (every week) - similar SEs to others - need be off opiates 1 week prior to starting and stop med 1 wk prior to any procedure when anticipating opiates
520
insurance and liraglutide
- will cover DM dose max 1.8 mg/d | - won't cover obesity dose max 3 mg/d
521
other GLP-1s for wt loss
- semaglutide looks promising
522
DM resolution after bariatric surgery
- occurs within days | - likely more related to gut as endocrine organ, not really wt loss
523
peds growth charts for obesity
- have extended growth charts for obesity that show elevated percentiles
524
overweight peds
- 85-94.9%
525
obesity peds
>95th%
526
class 2 obesity peds
>120th% of 95th%
527
class 3 obesity peds
>140th% of 95th%
528
difference in fat distribution peds
- males more visceral | - females more SC
529
risks for peds obesity
- AA, hispanic - low SES - parental obesity - parental DM or other wt co-morbidities
530
which chart to use for peds
- <2 y/o use wt for ht | - >2 y/o use BMI
531
peds screening labs for obesity
consider labs in overweight, get in all obese - lipids - LFTs - fasting glucose - A1c - TSH - Vit D - UA, urine micro/Cr - consider PFTs and sleep study
532
medical risks of obesity in peds
- depression - asthma - OSA - glomerulosclerosis/proteinuria - NASH/NAFLD - gallstones - risk cirrhosis and colon CA - forearm fx - blount's dz - SCFE - DDD risk - IIH (pseudotumor cerebri) - risk for CVA - HLD - HTN - LVH - risk CAD - DM2 - precocious puberty - PCOS - hypogonadism (boys) - hernia - DVT/PE - stress incontinence - risk gyn malignancy
533
ABCD
adiposity based chronic disease - new wording to try to encompass the idea that obesity is not just a number but is more significant when linked to chronic conditions - puts patients into stages - still investigational - trying to use instead of obesity which is only a number and leaves out a number of factors - used to describe the disease state and not just the number - "complication-centric" framework of care
534
ABCD factors
- pt must be activated to change - key drivers and associated abnormalities need identified - need to identify risk, presence, and severity of adipose related chronic conditions - careplan needs developed for tx
535
BMI changes over time (prevalence)
- all increasing, but higher BMIs are rising even faster
536
super obesity
``` - class 4 BMI 50-59.9 ```
537
Super super obeisty
``` - class 5 BMI >60 ```
538
surgical challenges in super obesity
- more hepatosteatosis - magnitude of visceral fat - lack of reliable anatomical markers, poor visualization in surgery
539
best surgery of super obesity
- studies show more initial wt loss with RYGB, but in long-term is comparable to sleeve - wt decreases, but BMI still likely to be >40 and will need additional interventions - best to add AOBM after surgery to give additional wt loss
540
how to dec diarrhea with metformin
- lower carb - lower fat - higher prot
541
GLP-1 and fatty liver
- help to dec cholesterol | - dec degree of hepatosteatosis and dec risk for fibrosis
542
key characteristics of genetic variant causing obesity
- hyperphagia (insatiable appetite) | - early onset, severe obesity
543
hyperphagia definition
- insatiable appetite - sev preoccupation with food seeking behavior or food - heightened and prolonged hunger
544
prader-willi syndrome
- FTT in infancy - onset of hyperphagia between 3-15 yrs - hyperphagia can continue into adult hood - distress and beh issues if denied food - short stature - GH def - hypogonadism - severe neonatal hypotonia, poor suck - intellectual disability - dysmorphic facial features - small hands and feet
545
bardet-biedl synd
- wide range of ht, may look fairly normal - hypogonadism - food seeking and over-eating - typically no distress with not being able to have food - visual impairment - cognitive disability - polydactyly - renal dysfunction - specific criteria to dx: 4 primary or 3 primary and 2 secondary
546
MC4R def
- 1:2000 - inc lean body mass and accelerated linear growth - hyperinsulinemia - may have lower BP - differing degrees of hyperphagia and obesity depending on genotype
547
PCSK1 def
- persistent diarrhea, intestinal malabsorption, and FTT in infancy - hypoglycemia - hypothyroid - adrenocorticotropic horm def - hyperphagia develops after
548
leptin actions in hypothalamus
- activates POMC and AgRP/NPY neurons - POMC activates MC4R neurons causing dec hunger, dec food intake, and inc energy - AgRP/NPY path act to inhibit POMC signal to MC4R
549
leptin def
- normal linear growth with dec adult ht - hypogonadotropic hypogonadism - hypothyroid - immune abnormalities
550
POMC def
- accelerated childhood growth - adrenocorticotropic horm def - mild hypothyroid - red hair, light skin
551
Alstrom synd
- short stature - DM2, insulin resistance - hypogonadism - hyperandrogenism in females - hypothyroid - visual impairment - hearing loss - cardiomyopathy - hepatic dysfunction - renal failure
552
Tx of genetic disorders
- need multidisciplinary approach - if able, tx the actual deficiency - can consider other AOM and surgery, but need to address the deficiencies
553
Health related quality of life in peds with obesity
- similar reported QoL to children with cancer | - more at risk if autism and Down's syndrome
554
mental health risks in peds obesity
- preschool wt that is high increased risk for utilization of mental health services - higher weight, higher distress - more depression in girls - 25% of girls use extreme ways to try to control obesity (ie purging, pills, etc) - greater degree of suicidal ideation (but not attempts) - feel less smart - increased anxiety
555
% children with reported depression
- 54% with significant symptoms | - only 10% report no symptoms
556
white fat structure
- unilocular lipid droplet - few mitochondria - energy storage
557
brown fat structure
- numerous small fat droplets - many mitochondria - energy dissipates - causes "uncoupling of thermogenesis" - found more in younger, women, and more active people
558
beige fat structure
- dissipates energy - activity is very inducible - present in all adults - can be recruited to brown fat and improves insulin sensitivity and utilization
559
how to activate brown fat
- cold - NE/epinephrine - main fuel is free fatty acids and glucose - has lots of beta-3 rec, so also see inc HR and BP when activated
560
CVOT
- cardiovascular outcome trial - FDA requires as post-marketing requirement for AOM - to get statistical power often recruit older people with heart issues, DM, etc - primary composite endpoint is MACE (major adverse cardiac events) - designed for non-inferiority trial to placebo
561
qysmia cardiovascular warning
- warning for only phentermine has been withdrawn for qysmia - not actually contraindicated in cardiac dz, CVA, CAD, CHF, arrhythmia, heart failure - warning was based on MOA not actual clinical trials - however, the effect on patients with these conditions has not really been well-established (none reported in drug trials, but no COVT has been done)
562
contrave and cardiovascular dz
- contraindicated in uncontrolled HTN | - effect on cardiovascular M&M not well established
563
AAP recommendation for lipid screening in peds
- screen risk factors at birth - starting at 2 y/o if high risk condition - universal screening in 9-11 y/o - one more screen at 17-21
564
high risk conditions for peds HLD
- DM1 and 2 - CKD - renal transplant - postorthotopic heart transplant - kawasaki dz with aneurysm
565
mod risk conditions peds for HLD
- kawasaki dz with regressed aneurysm - autoimmune dz - HIV - nephrotic synd
566
lipid screening guideline for 2-8 y/o
- screen if FH MI, CVA, CABG at < 55 y/o males or <65 y/o females - parent with TC >240 or known dyslipidemia - child with DM, HTN, BMI >95th%, or smoking - child with mod/high risk condition
567
peds TC goals
<170 | >200 is high
568
peds LDL goals
<110 | >/= 130 is high
569
peds TG goals
- 0-9 y/o <75, >/=100 is highg | - 10-19 y/o <90, >/=130 is high
570
peds HDL goals
>45 | <40 is low
571
17-21 y/o TC goal
<190, >225 is high
572
17-21 y/o LDL goal
<120, >160 is high
573
17-21 y/o TG goal
<115 | >150 is high
574
17-21 yo HDL goal
>45 | <40 is low
575
lipid screening concerns in peds
- no clear benefit - may lead to over dx and over-treatment - cost - treatment unknowns in peds
576
nutrition guidelines for elevated cholesterol in peds
- 25-30% calories from fat - <7% saturated fats - <200 mg cholesterol - plant sterols to replace other fat sources - add fiber to diet 6-12 g/day - 1 hr mod PA per day - <2 h/d screen time - dec sugar intake - complex instead of simple sugars
577
when to tx HLD with meds peds
- severe primary hyperlipidemia (ie familial) - high risk condition - evidence of CAD - all care should be under lipid specialist
578
how to screen peds for HLD
- use non-fasting lipid panel first | - fasting if non-fasting is near referral/medical tx level
579
endoscopic gastric therapy metabolic effects
- dependent on wt loss
580
endoscopic small bowel therapy metabolic effects
- independent of weight loss
581
small bowel endoscopic therapies for wt loss
- bypass liners (duodenojejunal, gastroduodenojejunal) - intestinal bypass - duodenal mucosal resurfacing
582
intensity of lifestyle visits and wt loss
- low intensity (<6 in 6 mths) no wt loss - mod intensity (6-13 in 6 mths) 5% loss - high intensity (>14 in 6 mths) up to 10%
583
obalon balloon system
- swallow capsule - filled with nitrogen gas that fills balloon in stomach - could allow for in office procedure - most use multiple capsules - GI removes balloons - 30% have heartburn, so if already have not good option - less N/V than other intragastric devices
584
travel with intragastric balloons
- can't be at sea level >3 wks or need to get balloon out | - where lived in relation to where placed matters
585
Aspire aspiration device SE
- hypoK, may need replacement
586
transpyloric shuttle
- tube placed across pylorus with balloon in stomach - intermittently blocks pylorus causing delayed gastric emptying - keep in 12 mths
587
pill balloon in production
- elipse balloon - capsule swallowed and then filled with saline - at 4 mths will self-deflate
588
duodenal mucosal resurfacing
- high fat diet actually changes our mucosal lining - use hydrothermal ablation of hyperplastic mucosa - regrowth is normal mucosa
589
Stop eating CRAP
- carbonated drinks - refined sugars - artificial foods - processed foods
590
Meal order to help with weight loss
- protein - veggie - carb
591
non-nutritive sweetners
- limit or avoid - still cause increase in insulin and obesity - may not have calories but still inc weight - increased risk for CAD - people often use too much and cancels out the other calories they are cutting
592
odds for childhood obesity with early wt gain
- risk higher with very rapid wt gain (crossing of >/= 2 lines)
593
Mothers diet and infant food preference
- flavors from mothers diet may get into breast milk and amniotic fluid - can influence food preference in infants later - may be more accepting of different foods
594
Restrictive feeding in peds
- may lead to weight gain
595
risk for DM2 in young adults with wt gain
30% higher
596
risk for HTN in young adults with wt gain
14% higher
597
risk for CAD in young adults with wt gain
8% higher
598
SES and obesity
- increased risk if not graduate high school - inc risk if low income - inc ped risk if family low SES - girls in low SES more likely than boys - in adults less of a discrepancy with obesity related to income
599
men obesity with SES
- similar between incomes | - higher incomes may actually have more
600
women obesity with SES
- inc in low SES
601
barriers to weight loss in AA women studies
- lack of time - access to resources - food is sense of pleasure - identification with larger body size (cultural) - pressure to conform - fears about bariatric surgery - thinking surgery is too extreme
602
treatment challenges with AA trials
- tend to have less weight loss showing metabolic differences between races - great insulin secretion in AA and more insulin resistant - can see inc in A1c after surgery
603
inheritability of obesity
- up to 70% heritable | - genes related to CNS function
604
key psychological skills need for wt loss and maintenance
- restraint | - resilience
605
CBT for wt loss
- address problem feeding behavior and emotions - replace dysfunctional thinking with helping thinking - improves binge eating and depression
606
unhelpful thinking styles
- all or nothing thinking - mental filter (only look at certain evidence) - jumping to conclusions - emotional reasoning - labelling - over-generalizing - disqualifying the positive - magnification and minimization - use of should or must can make us feel guilty - personalization
607
step approach to CBT
- identify thoughts preceding bad behavior - label the sabotaging thought ( giving yourself permission to cheat, being self-critical) - challenge that thought (is it really true) - summarize the evidence to replace with new realistic thought
608
how to build resilience
Set expectations: - lapses are normal - look at other obstacles the pt has overcome - address internal bias about weight - reiterate obesity as a dz
609
peds obesity and fx risk
- higher wt would think more bone density | - but have inc fx risk
610
obesity impact on bone
- higher volumetric BMD - inc cortical thickness and porosity - inc trabecular number and thickness - inc failure load - however, amt of inc is not enough for adaptation to higher wt
611
type of fat and BMD
- positive association with SC - conflicting assoc with visceral (likely have worse BMD) - ratio of VAT/SAT is important neg predictor for bone outcomes (higher number is worse)
612
mediators of fat relation to BMD
- leptin- inc cortical bone - adiponectin- stimulate osteoclast differentiations and effects - inflammation stimulate osteoclast activity
613
marrow adipose tissue and BMD
- inverse relationship - higher MAT leads to lower BMD - more seen in trabecular bone
614
MAT in obesity
- higher MAT, so dec BMD | - DM also inc MAT
615
wt loss surgery and bone
- causes dec BMD and change in architecture - likely related to dec leptin, PYY - have long-term inc fx risk
616
how breastmilk dec obesity
- role of microbiome from milk - less overfeeding - self-regulation of intake
617
obesity and breastfeeding
- overweight/obese same likelihood to initiate breastfeeding, but more likely to stop at d/c - obese women don't breastfeed as long
618
obesity and difficulty with breastfeeding
- get dec mammary epithelial gland cells - increased adipocyte cells - see more flattened breasts, flat nipples - higher androgen/DHEA levels in pregnancy make difficulties with breastfeeding - inc risk C/S, difficult labors, etc which can disrupt breastfeeding - dec milk production with insulin resistance - dec prolactin in 1st 48 hrs - higher leptin levels which inhibits some oxytocin
619
nutrition for breastfeeding women
- min calories 1500 - need extra 500 cal when breastfeeding - generally avoid ketogenic diets - need min 50g carb/day - meal replacements okay - fasting may be okay - do frequent nutritional labs if h/o bariatric surgery - may need extra vit D and B12
620
AOM in breastfeeding
- metformin, wellbutrin, and saxenda okay | - avoid topamax, naltrexone and phentermine
621
pediatric characteristics for improved wt loss
- older age >12 y/o - greater severity of obesity - hispanic
622
peds wt loss and improvement in metabolic
- need 5% wt loss to see improvement in cardio-metabolic risk factors
623
binge eating disorder criteria
- recurrent episodes of binge eating - episodes associated with 3 (eating more rapidly than normal, eating until uncomfortable full, eating large amts when not hungry, eating alone b/c embarassed, feeling disgusted in self) - marked distress regarding behavior - episodes occur at least 1x/wk for 3 mths - not associated with compensatory behavior
624
binge eating definition
- eating in discrete period of time amount of food that is larger than most people would eat in that time - sense of lack of control over eating
625
overeating vs binge eating
- overeating does come with same amount of distress about the behavior
626
binge eating states
- most common ED - affects 1-3% population - more in females - avg age 15-25 - 80% have concurrent psych dz
627
night eating syndrome
- recurrent episodes of waking to eat or excessive food consumption (>25% daily calories) after evening meal - morning anorexia - insomnia - tend to be carb heavy foods - nocturnal awakenings to eat are common - causes impairment and distress
628
night time eating stats
- 1.5% population - females have more sev symptoms - relapsing/remitting with stressors - 15-20% also have BED
629
BED and co-morbidieis
- more sev depression - higher BMIs - severe OCD - sleep problems - feel more inadequate or inferior
630
obesity related eating behaviors
- emotional eating - binge eating - external eating - reactivity to food cravings - restrained eating - mindless eating
631
BED tx
- CBT - Dialectical behavioral therapy (DBT) (mindfullness, emotional regulation, distress tolerance) - interpersonal therapy - normalized eating - medications
632
CBT outcomes in BED
- dec binge frequency and days - dec depression - dec pre-occupation with food - no effect on wt
633
Medication to tx BED
- lisdexamfetamine - only FDA approved med for mod to sev BED - MOA - 30 mg/day - inc up to 50 mg/da - max dose 70 mg/day - not used for wt loss, but does lead to wt loss
634
mod BED
- 4-7 episodes/wk
635
sev BED
- 8-13 episodes/wk
636
topamax and BED
- not FDA approved - conflicting evidence if improves binging - most have wt loss - topamax + CBT may work best
637
2nd generation antidepressants and BED
- duloxetine, venlafaxine, wellbutrin, mirtazipine - helps with depression and bingeing - no change in wt
638
night eating syndrome tx
- CBT - SSRI (zoloft shown to help in studies) - progressive m relaxation - phototherapy - normalized eating (regular meal consumption) - inc protein
639
healthy at every size approach
(HAES) - supports health behaviors for all sizes without using wt as a mediator - teaches weight inclusivity and body acceptance - health enhancement - life enhancing movement - eating for being - respecting yourself
640
issues with wt focused diet and health plans
- cause food and body preoccupation - distracts from personal health goals and other health outcomes - dec self-esteem - contribute to eating disorders - make wt stigma
641
Intuitive eating
Another name for HAES - rejects diet mentality - honors hunger - make peace with food - challenge the food police - feel your fullness - discover the satisfaction - cope with emotions without food - respect your body - exercise to feel a difference - honor health
642
HAES vs diet
- maintain wt - improves lipids and BP - improves energy expenditure - improves eating behaviors - inc self-esteem - dec depression - dec body image issues
643
Bulimia nervosa definition
- recurrent episodes of binge eating - recurrent inappropriate compensatory behavior to prevent wt gain occur 1x/wk for 3 mths - preoccupation with body shape and wt
644
BN stats
- 1-1.5% population - more females - more in late teens and 20s - 1/3 are obese - 1/3 with other substance use disorders
645
BN tx
- CBT (combo with SSRI best) - DBT - fluoxetine (FDA approved) - zoloft - topamax, trazodone, and zofran are off label - DON't use wellbutrin due to seizure risk
646
meal replacements for weight loss
- lower calorie, but higher protein helps to burn fat and not lose lean mass - older products lacked electrolytes and other nutrients so caused issues
647
meal replacements and weight loss
- have more weight loss with combining medication, behavior modification, and meal replacement
648
benefits of meal replacement
- portion and calorie control - improved nutrition - structured eating - simplified food choices - avoiding trigger foods - protein leverage
649
effects of protein
- dec appetite - inc satiety - inc thermic effect of food
650
high protein diet content
- 1.2-1.6 g prot/kd/d of IBW | - at least 25-30 g protein/meal
651
meal replacement pros for office
- easy to use - good for pt with limited planning - good for busy people - easy to give structured eating plan - revenue can help fund other areas - elimination diet
652
VLCD meal replacements
- higher levels of potassium and Na so won't get low - need to use complete product, not just supplement - but don't want total/complete meal product that is NL daily calories which are more for wt maintenance - NL use 5 products per day to get daily calories - think about adding med to help dec appetite
653
labs on VLCD
- initial, 2 wk, 4 wk, then monthly - CMP, mg, Ph - will see transient inc in LFTs with wt loss, if >3x ULN may need additional replacement product or regular food
654
VLCD potential pts
- need wt loss for surgery - post-surgery wt regain - failed other options - DM
655
VLCD cautions
- CHF - DM CKD/ESRD
656
types VLCD products
- bariatric advantage - bariatrix nutrition - optavia - optifast - robard
657
malnutrition risks
- restrictive procedures - vegetarian - lactose intolerance - celiac/gluten free - food allergies - budget, homeless - edentulous - bowel resection - IBD
658
percent iron def after surger
30%
659
Anemia not improved by iron, B12, folate
- consider other def like Cu, Zn, Vit A, Vit E
660
lipedema
- "stove pipe legs" more nodular fat - non-pitting edema
661
painful fat
- dercum's dz | - adiposis dolorosa
662
lymphedema vs lipedema
- lymphedema also involves dorsal aspect of feet | - lipedema has easy bruising
663
waist to hip ratio for obesity
hip measured at superior iliac crest - women >0.8 - male >1:1
664
resting metabolic rate components
makes largest portion of daily energy expenditure - 15% brain - 7% heart - 5-10% kidney - 25% muscle - 4% adipose tiss
665
metabolically healthy with obesity
- MHO | - subset of people with obesity that have no metabolic dz
666
metabolicaly obese, normal weight
- MONW | - NL wt but have metabolic issues
667
who to screen with EKG
- symptomatic - cardiac risk factors - strong FH - medications - pre-exercise eval - pre-op eval
668
obesity EKG abnormalities
- LAD - T waves - PACs (OSA) - Hypertrophy - QT abn
669
secondary obesity w/u
- PCOS - hypogonadism - cushings - hypothalamic/pit
670
who to get screen abd u/s
- NAFLD - nephrolithiasis - PCOS
671
who get sleep study
- pos screen - neck >17 male and 16 female - fatigue - mallampati 3-4 - HTN
672
B1 def s/s
thiamine - wet beriberi (CVD) - dry beriberi (neurologic) - wernicke-korsakoff synd (ataxia, oculomotor dysfunction, confusion)
673
B2 def s/s
Riboflavin - anemia - mouth/lip/skin disorders
674
B3 def s/s
Niacin | - pellagra- dermatitis, dementia, diarrhea
675
B6 def s/s
Pyridoxine - coordination - mental changes - oral lesions
676
B9 def s/s
Folic acid - macroytic anemia - glossitits - NT defects
677
B12 def s/s
Cyanocobalamin - macrocytic anemia - dementia - balance - peripheral neuropathy
678
Vit C def s/s
- scurvy - bleeding gums - poor wound healing
679
calcium def s/s
- osteoporosis - osteomalacia - poor dentition
680
iron def s/s
- microcytic anemia
681
zinc def s/s
- poor wound healing | - impaired immunity
682
copper def s/s
- anemia - leukopenia - myeloneuropathy
683
selenium def s/s
- fatigue
684
iodine def s/s
- thryomegaly | - cretinism
685
chromium def s/s
- insulin resistance
686
Loss of control eating disorder (LOC-ED)
- for children <12 who display binge type eating - similar criteria to BED - assoc with ADHD
687
graze eating
- repetitive and unplanned eating of small amount of food - may include sense of loss of control - can't stop or resist eating - compulsive disorder
688
wt in BN
- 80% normal weight - 10% overweight - 10% underweight
689
complications of BN
- perimolysis (tooth enamel erosion) - scarring of back of hands - swollen salivary glands - SI
690
AN criteria
Need 3/3 - restriction of energy intake causing low weight (BMI <18.5) - intense fear of gaining weight - distorted body image - amenorrhea no longer necessary to diagnose
691
Types AN
- restricting type | - binge eating/purging type
692
AN severity
Based on BMI - Mild BMI >17 - mod BMI 16-16.99 - sev BMI 15-15.99 - extreme <15
693
AN complications
- anemia - hypoK, hypoMg - metabolic alkalosis - amenorrhea - osteoporosis - inc ventricular to brain ratio - abn LFTs - impaired renal function - death
694
Body dysmorphic disorder
- appearance preoccupations (normally something that wouldn't really seem abn) - repetitive behaviors compulsive beh in respo to appearance concerns) - distress/impairment in areas of life
695
BDD tx
Most off- label - SSRIs - CBT - topamax - lamictal
696
Body image dissatisfaction
- neg thoughts and feeling about body - associated with AN and BN - tx CBT
697
Risks for OSA
Should have in-lab study not HST - obesity (BMI >35) - pre-op for bariatric surgery - high risk occupation - CVA - CHF - DM2 - Afib - refractory HTN - nocturnal dysrhythmia - pulm HTN
698
mallampatic score
- Class 1- soft palate, tonsills, and uvula visible - class 2- soft palate, partial tonsills, and uvula visible - class 3- soft palate and base of uvula visible - class 4- hard palate visible
699
OSA dx criteria
- AHI >15/hr or 5/hr with symptoms
700
OSA severity
- mild AHI 5-14 - mod AHI 15-29 - sev AHI >30
701
obesity hypoventilation syndrome
- obesity BMI >30 - PaCO2 >45 - often co-existing OSA - serum bicarb often >27
702
Complications OHS
- high mortality - pulm HTN - R sided CHF
703
Tx shift work sleep disorder
- planned sleep - light exposure - daytime melatonin - daytime hypnotics - evening stimulants caffeine, modafinil)
704
Sleep related eating disorder
- 1-5% population - 80% have other sleep issue (RLS, PLMS, somnambulism) - inc with stress - associated with hypnotic use and antipsychotics
705
sleep related eating disorder tx
- remove any offending meds - tx associated disorders - topamax - SSRIs - trazodone - CPAP if OSA
706
Motivational interviewing RULE
- Resist trying to fix the problem for them - Understand their motivation - Listen - Empower them to make their own decisions
707
Motivational interviewing principles
- express empathy - develop discrepancy - roll with resistance - support self-efficacy
708
Motivational interviewing skills OARS
- open questions - affirmations - reflections - summaries
709
Change talk
- pt's words that favor movement in the direction of change | - what we try to encourage
710
DARN to show movement towards change
- Desire to change - Ability to change (can, could) - reasons to change (if... then) - need to change
711
Readiness scale
- ask 1-10 how important or read to change | - helps to determine barriers and motivators
712
SMART goals
- specific - measurable - achievable - realistic/relevant - timely
713
stages of change
- pre-contemplation - contemplation - preparation - action - maintenance
714
pre-contemplation
- no intention to change | - unaware of need to change
715
goal in pre-contemplation
- build self-awareness | - explore ambivalence
716
contemplation
- aware that problem exists | - interest in changing in 6 mths
717
goal in contemplation
- explore pros and cons | - resolve ambivelence
718
preparation
- open to and willing to change in next 30 days
719
goal in preparation
- set small, realistic goals | - develop action plan
720
action
- initiation of change | - committing to goal
721
goal in action
- reward behavior | - social support
722
maintenance
- continued change >6 mths
723
goal in maintenance
- lapse and relapse management | - continued goal setting
724
behavior therapy
- reinforce or extinguish behavior - give rewards - aversive stimuli - restructure environment
725
components of behavior therapy
- self-monitoring - stimulus control - problem solving - goal setting - contingency management - enlisting social support - relapse prevention - stress management - rewards - ongoing contact
726
dialectical behavior therapy
Form of CBT - focuses on mindfullness, interpersonal effectiveness, emotional regulation - uses beh therapy to teach life skills
727
interpersonal therapy
- part of motivational interviewing - focuses on resolving mood effects from interpersonal conflicts - goal to promote positive interactions with others - improves assertiveness - helps pt use social supports
728
prevalence obesity among US adults
40%
729
prevalence adults overweight or obese
70%
730
Adult age most correlated with obesity
40-59 y/o
731
cost of obesity
As wt increases, cost inc exponentially - inc total medical cost - inc chronic conditions - inc rates of hospitalization - inc physician visits - inc med use
732
environmental factors affecting obesity
- heavy metals - stress - poor sleep - prenatal influence - chemical exposures- BPA, arsenic, chromium
733
most common obesity syndrome
- MC4R syndrome
734
mortality and obesity
- mortality increases 30% for each 5 kg/m2 inc in BMI | - BMI 40-45 dec life by 8-10 yrs
735
change in BP with wt loss
- for each 1 k loss, SBP and DBP dec by 1
736
risk of CHF with inc BMI
- inc 2 fold with BMI >30
737
risk obesity and afib
- every 1 U BMI inc inc risk for afib by 4%
738
risk CVA with obesity
- 1 U inc BMI increases hemorrhagic CVA by 6% and ischemic CVA by 4%
739
NAFLD prevalence in obesity
- 90% in BMI >40 - 55-75% in BMI >30 - becoming most common indicator for liver transplant
740
risk depression with obesity
- BMI >30 inc risk 1.5-2x
741
calorie definition
- amt of heat required to raise temp of 1 g H2O by 1 degree C
742
RDA
recommended daily allowance
743
AI
adequate intake | - used when RDA cannot be determined
744
UL
tolerable upper intake level | - highest amt able to not cause toxicity
745
EAR
estimated average requirement | - amt estimated to meet requirement of 1/2 needed
746
DV
daily value
747
acceptable range for protein
10-35%
748
acceptable range for carbs
45-65%
749
acceptable range for fat
25-35%
750
carb kcal/gm
4
751
fat kcal/gm
9
752
protein kcal/gm
4
753
water kcal/gm
0
754
RDA carbs
130 g/d
755
RDA fat
30 g/d
756
omega 6
linoleic acid
757
omega 6 RDA
7-17 g/d
758
omega 6 sources
- nuts, seeds - vegetable oils - safflower and corn oil
759
omega 3 RDA
.5-1.6 g/d
760
omega 3 sources
- vegetable oils - canola and flax seed oil - fish oil - fatty fish - some meat and eggs
761
saturated fat sources
- animal fat - coconut oil - palm oil
762
protein RDA
- men 56 g/d | - women 46 g/d
763
protein for wt maintenance
- 0.7-1 mg/kg/d
764
protein for weight loss
1. 2-1.5 mg/kg lean body wt/d | - normally 90-120 g/d
765
essential amino acids
- histidine - isoleukcine - leucine - lysine - methionine - cysteine - phenylalanine - tyrosine - threonine - tryptophan - valine
766
respiratory quotient
- use to help predict BMR - ratio CO2 produced to O2 consumed - can help det which macronutrients are being metabolized
767
% post-bariatric surgery that need parenteral iron
20-30%
768
B12 def reasons
- pernicious anemia- autoimmune disorder against IF - gastric bypass- loss of parietal cells and IF - metformin- dec B12 absorption - vegan- inadequate intake B12
769
causes folate def
- unhealthy diet with little fruits/veggies - dec absorption (IBD, celiac) - genetic disorders - meds (phenytoin, sulfasalazine, bacrim, OCP) - alcohol - tobacco
770
B7 def
biotin - rare - alopecia - conjunctivitis - dermatitis - neuro- depression, hallucinations, paresthesia
771
what absorbed in duodenum
- iron - Ca - has bile and digestive enzymes - neutralizes stomach acid
772
what absorbed in jejunum
- carbs - AA - many vitamins - K - Iron - Ca
773
what absorbed in ileum
- water - K - minerals - slats - fats
774
what absorbed in colon
- Vit K - biotin - B12 - thiamine - riboflavin - water - Na - Cl
775
what secreted in colon
- K | - bicarb
776
Ca and obesity
body fat high in low Ca intake - low Ca cause inc PTH - inc vit D - high intracellular Ca - inc lipogenesis and dec lipolysis - net effect is inc fat stores
777
ADA exchange non-starchy veggies
- 2g prot - 5 g CHO - 25 cal
778
ADA exchange protein
- 7 g prot - 0-8 g fat - 35-100 kcal
779
ADA exchange fat
- 5 g fat | - 45 kcal
780
ADA exchange diary
- 8 g prot - 12 g CHO - 0-8 g fat - 90-150 kcal
781
ADA exchange fruit
- 3 g prot - 15 g CHO - 60 kcal
782
scale of glycemic index
- low <55 - med 56-69 - high >70
783
things that affect glycemic index
- preparation of food- fat, fiber, and acid lower the GI - ripeness - other foods eaten at same time- if combine high and low GI at same time is better - age - activity level - speed of digestion - DM/gastroparesis
784
VLCD vs LCD
- no difference in long-term wt loss | - more complications with VLCD
785
wt loss and lipids
- dec total cholesterol and LDL
786
low carb diet and lipids
- lower TG - lower VLDL - inc HDL
787
low fat diet and lipids
- more LDL lowering
788
mediterranean diet health benefits
- lower CV mortality | - dec DM2
789
vegan diet benefit
- lower LDL - dec CV mortality - dec DM2
790
DASH diet benefit
- dec BP
791
higher prot, lower GI benefit
- wt maintenance
792
metabolic adaptation to wt loss
- 10% wt loss causes dec energy expenditure/BMR and inc m efficiency - total energy expenditure dec by 20-25% - will take 300-400 fewer calories/d to maintain same wt compared to someone who didn't lose weight - persists for years
793
omega 3 types
- ALA - EPA - DHA
794
how to det g prot
g prot/7 = ounces of protein
795
AA that can convert
can change within each other - methionine/cysteine - phenylalanine/tyrosine
796
ghrelin
- most potent hunger hormone - stimulated when stomach empty - inc hunger and dec energy expenditure - inhibited when stomach stretches with eating
797
ghrelin pathway
- stimulated NPY/AgRP in hypothalamus | - travels through vagal n and nucleus tractus solitarius
798
ghrelin in obesity
- have less of a ghrelin drop after eating which causes to remain hungry
799
factors that inc ghrelin
- fasting - wt loss - stress - sleep deprivation - genetics/syndromes (Prader willi)
800
factors that dec ghrelin
- meals - wt gain - leptin - sleeve gastrectomy
801
foods and ghrelin suppression
- CHO suppresses that fastest, but faster rebound | - prot suppresses the longest
802
SI hormones for satiety
- CCK - GLP-1 - OXM (oxymodulin) - PYY
803
CCK
- made by L-cells of SI - sec due to fat and prot - short acting - stimulates GB contraction - slows gastric emptying
804
GLP-1
- made by L cells SI - sec due to CHO - inc insulin secretion - suppress glucagon - dec gastric emptying - dec appetite
805
GLP-1 levels dec in
- obesity - preDM - DM2
806
OXM
- made by L-cells SI - binds to GLP-1 rec - acts like GLP-1 - being explored as medication
807
PYY
- made by L-cells SI - binds to Y2 rec - potent appetite suppressant - dec gastric emptying - being explored as med

Medical Study (20 decks)

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