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Lifestyle Medicine > Obesity Management > Flashcards

Obesity Management Flashcards

1
Q

What are the 3 main tools for diagnosing overweight/obesity

A
  1. BMI
  2. Waist circumference
  3. Edmonton Obesity Stages System
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2
Q

BMI

  • calculate
  • levels and classes
  • As a measurement: is it preferred? what populations do we use it/not use it on?
A

weight (kg) / height (m^2)
or
weight (Ibs) x 703 / height (inches^2)

<18.5 underweight; class 0
18.5-24.9 normal; class 0
25-29.9 overweight; class 0
30-34.9 obese; class I
35-39.9 obese; class II
>40 obese; class III
  • BMI is the preferred measure of adiposity
  • still need other health measures
  • used for most adults 18-65, excluding: those with high muscle mass (body builders, long distance athletes); those with lower muscle mass (children) or those losing muscle mass (elderly); and pregnant/lactating people
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3
Q

BMI clinical applications (5)

BMI limitations (1) and misinterpretations (3)

A
  • screens for overweight/obesity (and health risks)
  • predicts future morbidity and death
  • track changes in weight
  • refer patients who may benefit from obesity management specialists
  • categorize cardio-metabolic risk of patients
  • measures weight only, not body composition (fat vs muscle vs bone)

Misinterpretations:

  • older adults have more fat with same BMI as younger ppl
  • women have more fat with same BMI as men
  • muscular people have higher BMI because of high muscle mass
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4
Q

Pediatric obesity classification

  • what age can BMI be used?
  • how do we track pediatric BMI?
  • classification of obesity in children?
A
  • children over 2 years (to see if they are at risk for obesity and overweight)
  • use BMI-for-age growth chart
  • overweight: 85th percentile =< BMI-for-age <97th percentile
  • obese: 97th percentile =< BMI-for-age <99.9th percentile
  • severe obesity: BMI-for-age >= 99.9th percentile
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5
Q

prevalence of obesity in Canada

A

increasing every year

** obese classes II and III are increasing at disproportionate levels

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6
Q

Adult waist circumference

  • what should it be (in 3 categories?)
  • how to measure?
A

Canada, USA
Women: >=88cm
Men: >=104cm

caucasian/europoid, middle eastern, mediterranean, sub-saharan African:
Women: >=80cm
Men: >=94cm

Asian, central and south american
Women: >=80cm
Men: >=90cm

–> measuring tape just above ASIS; tighten around waist without depressing skin; recommended to use calibrator

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7
Q

Adult waist circumference clinical implications

A
  • distribution of body fat is an indicator of health risk
  • abdominal fat is most biologically active (releasing cytokines, inflammation, and insulin resistance)
  • high waist circumference is associated with a high risk for CVD and T2D
  • measuring waist circumference can screen for people who have normal BMI, but more abdominal fat (different fat distribution, normal BMI - high risk for obesity related illness and death)
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8
Q

Edmonton Obesity Staging System (EOSS)

- what is it for?

A
  • staging system designed to complement BMI, to describe severity of obesity
  • independent of BMI; for those who are already obese
  • to describe morbidity and functional limitations associated with excess weight (5 graded categories, 0-4)
  • independently predicts mortality associated with obesity, independent of BMI
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9
Q

Edmonton Obesity Staging System

- describe each stage

A

Stage 0
- No: physical, psychological, functional, or obesity related risk-factors

Stage 1
- patient has subclinical obesity related risk-factors (borderline hypertension, elevated liver enzymes, impaired fasting glucose)
OR
- mild physical symptoms (joint pain, dyspnea on moderate exertion, fatigue) - not requiring medical treatment
OR
- mild obesity related psychological symptoms or impairment of well-being (QoL not affected)

**stages 0 and 1, no admission, refer to primary care for prevention methods

Stage 2
- patient has established obesity related co-morbidities requiring medical intervention (hypertension, diabetes, sleep apnea, PCOS, osteoarthritis, reflux disease)
OR
- moderate obesity related psychological symptoms (depression, eating disorders, anxiety disorders)
OR
- moderate functional limitations in everyday life (quality of life beginning to be impacted)

Stage 3
- patient has significant obesity related end-organ damage (MI, diabetic complications, heart failure, debilitating osteoarthritis)
OR
- Significant obesity related psychological symptoms (major depression, suicidal)
OR
- Significant functional limitations in everyday life (unable to work or complete routine activities, reduced mobility)
OR
- Significant impairment of well-being (quality of life severely impacted)

Stage 4
- Severe obesity-related comorbidities (possibly end-stage)
OR
- Severely disabling psychological symptoms
OR
- Severe functional limitations

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10
Q 
What stage and class is this?
- physically active female, BMI 32 kg/m2, no risk factors, no physical symptoms, no self-esteem issues, and no functional limitations
A

Class I; Stage 0

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11
Q 
What stage and class is this?
- 49 year old female with a BMI of 67kg/m2, diagnosed with sleep apnea, CV disease, GERD, and suffered from stroke, Patient's mobility is significantly limited due to osteoarthritis and gout
A

Class III; Stage 3

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12
Q 
What stage and class is this?
- 32 year old male with BMI of 36kg/m2, with primary hypertension and obstructive sleep apnea
A

Class II; Stage 2

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13
Q 
What stage and class is this?
- 38 yo female with BMI of 59.2kg/m2, borderline hypertension, mild lower back pain, and knee pain. Patient does not require any medical intervention
A

Class III; Stage 1

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14
Q 
What stage and class is this?
- 45 yo female with BMI of 54 kg/m2, who is in a wheelchair, because of disabling arthritis, severe hyperpnea, and anxiety disorder
A

Class III; Stage 4

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15
Q

EOSS clinical limitations

A
  • clinicians may disagree whether it’s obesity that caused the medical conditions
  • uses definitions of risk/comorbidities that may change with new research
  • subjective parameters to stage psychological factors
  • doesn’t capture weight related issues that occur at lower BMIs
  • doesn’t contain a measure for readiness to change
  • EOSS-P (pediatrics), is currently undergoing validation
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16
Q

Complications of Obesity (list)

- list common (don’t need to memorize)

A

psychological:

  • low self-esteem
  • depression
  • eating disorders
  • social isolation

pulmonary

  • exercise intolerance
  • obstructive sleep apnea
  • asthma

GI

  • GERD
  • gallstones
  • fatty liver disorder

Renal: glomerulosclerosis

MSK:

  • arthritis
  • pain
  • flat feet
  • multiple injuries (ankle sprains, forearm fractures)

CVD:

  • heart disease/failure
  • hypertension
  • dyslipidemia
  • endothelial dysfunction
  • chronic inflammation
Endocrine:
- metabolic disorder
- Type 2 diabetes
- menstrual irregularities
- PCOS
-
17
Q

Causes of Obesity

A
  • ultimately energy imbalance consumed > expended
  • complex and multifactorial
  • factors that influence obesity (environment, overconsumption of calories, physical inactivity, genes, health conditions, inadequate sleep patterns, medications, psychosocial)
18
Q

3 levels of obesity management

A
  1. surgery (for more severe)
  2. pharmacotherapy (for more severe)
  3. lifestyle changes (diet and exercise) - first line of treatment
    * *lifestyle modifications must be present throughout all levels of obesity treatment
19
Q

Obesity etiology:

  • what causes positive energy balance? (3)
  • what factors influence each of the 3 causes
A
  • imbalance of diet, metabolism, or activity
  • many factors can influence dietary consumption, metabolism, and activity level

diet and activity level:

  • sociocultural
  • biomedical
  • mental
  • medication

metabolism:

  • age
  • gender
  • genetics
  • hormones
  • skeletal muscle
  • medication
20
Q

Etiological Framework for assessment and management of obesity (4 steps):

A

STEP ONE: Assess energy requirements and metabolism
- Total Energy Expenditure (TEE) = Resting energy expenditure (REE) x Activity Factor (AF) x Stress Factors (SF)

STEP TWO: Assess determinants of obesity

  • increased caloric intake? slow metabolism? reduced activity?
  • 4Ms: framework for assessment of overweight and obese patients (mental, mechanical, metabolic, monetary)
  • identify primary areas of issues related to obesity causes (socioeconomic, mental, physical)
  • -> Mental: knowledge, information, mood, self-image, sleep
  • -> Mechanical: pain, osteoarthritis, reflux, apnea, thrombosis,
  • -> Metabolic: insulin resistance, PCOs, menstruation issues, type 2 diabetes, metabolic syndrome, dyslipidemia, gout, cancer, infertility
  • -> Monetary: education, employment, low income, disability, surgery, weight-loss programs,
  • the 4 Ms also help with EOSS staging

STEP THREE: Develop management plan

  • must address underlying cause with accompanying supports
  • -> patient who is self-medicating with food, identification and treatment of depression is first step of reducing food intake
  • -> patient with socioeconomic barriers to healthy eating/physical activity, refer to social worker
  • -> identification of obstructive sleep apnoea will be key to increasing physical activity
  • -> psychological counselling to manage alcohol and substance abuse or trauma, or eating disorders, can put patients on the path to weight maintenance
21
Q

Barriers to lifestyle and behavioural modifications

  • patient perceived
  • physician perceived barriers
  • how do you define success
A

Patient: emotional and social barriers (stress, depression, loss of motivation); food cravings and hunger; unsupportive environment; social pressures; lack of time, feeling tired; knowledge and skills; unrealistic expectations

Physician: lack of time to discuss; lack of patient readiness; inadequate knowledge of food, diet, and medical management of obesity; reluctance to address fatness in patients - “willpower” thing instead of serious health concern

Success:
patient-perceived:
- increased energy
- increased sleep quality
- increased self esteem
- increased meals made at home
- stairs instead of elevator

physician-perceived:

  • decreased rate of weight gain, stabilization, or loss
  • decreased waist circumference
  • improved biochemical markers
  • increased fitness ability
22
Q

Prevention and Management of obesity: Canadian Clinical Practice Guidelines 2006

A

Step 1: lifestyle modifications

satisfactory?
Step 2:
Yes –> regular monitoring, weight maintenance
- maintain healthy eating and exercise
- address other risk factors: monitor weight, BMI, waist circumference every 1-2 years

No –> pharmacotherapy

  • BMI >27 plus risk factors or BMI >30
  • if haven’t lost 1 pound per week, 3-6 months after intervention

No –> bariatric surgery
- BMI >35 plus risk factors or BMI >40

23
Q

Five As of managing obesity

A 
Ask:
- for permission to discuss weight
Assess:
- BMI in adults; percentile in children
- Stage obesity
- Figure out driving causes
Advise:
- obesity risks
- benefits of moderate weight loss
- discuss treatment options
Agree:
- agree on weight loss expectations (SMART goals)
- Specific, Measurable, Attainable, Realistic, Time-bound
Assist:
- in addressing barriers to weight loss, accessing resources, etc. 
- **Arrange for follow-up!!!
24
Q

Five As for physical activity

A

Ask:
- determine PAV (physical activity vital sign): minutes/day x days/week (goal of 150 minutes)
- how many days/week do you engage in physical activity?
- how many minutes?
Advise:
- tell patients about the guidelines (150 per week)
- add muscle or bone strengthening activities (2 days/week)
- tell patients of health benefits of exercise (reduce risk 25-50% of chronic diseases)
Assess:
- model of change (pre-contemplation, contemplation (intend to change in next 6 months), preparation (intend to change in immediate future), action (specific action in past 6 months), maintenance (made changes, working to prevent relapse), relapse)
Arrange:
- follow-up!

25
Q

3 key elements of motivational interviewing (blah not blah)

4 core principles of MI

4 core skills of MI

A
  1. autonomy not authority
  2. collaboration not confrontation (trust and rapport)
  3. evocation not imposing (drawing out patient’s ideas about change)

MI principles:

  1. empathy
  2. develop discrepancies
  3. roll w resistance
  4. support self-efficacy

MI Skills:

  1. start w open-ended questions
  2. affirmations
  3. reflective listening
  4. summaries

Lifestyle Medicine (1 decks)

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