1
Q
What has changed with obesity since 2007
A
= classified now as a chronic disease as a complex medical condition with lots of bias, stigma, and discrimination in patient-centrede care and outcoms beyond weight loss
2
Q
Definition of Obesity and how should it be diagnosed and managed
A
- previously as BMI and not health
now - prevalent complex progressing and relapsing chronic disease charecterised by abnormal or excessive body fat that impairs health - BMI and wasit circumference used as screening tools
- diagnosis shoul dbe based on presense of functional medical or psychosocial impairemnets related to the presense of abnormal or excess body fat rather than on anthropometric measures alone
- should be managed using evidence based chronci disease managment validate lived experiences move beyond the simplistic approaches of eat less and move more address root drivers of obesity
- peopple who are living with obesity should have eccess to evidence informed interventions which should include medical nutrition therapy PA psychological interventions and pharmacotherapy
3
Q
Recognizing and addressing weight bias
A
- people living with obesity face substantial bias and stigma which directly ipacts their health and well being as well as access to care
- health care providers should asess their own beliefs. and attitudes towards people living w obesity
also know about internalized weight bias the attitudes of people living with obesity affect behavioral and health outcomes
avoid using judgemental words images and practices when working with patients living with obesity - avoid making assumptions that an ailment or complaint a patient presents w is related to body weight
4
Q
Appraoch to obesity management 1st A
A
Ask - recognition of obesity as a chronic disease by the health care providers who should ask the pateint permission to offer advice and help trat this disease in an unbiased manner
- acknowledge that obesoty is complex chronis and required individualised treatment and long term support
- weight bias check for it in urself
- dont addume all patients with obesity want to manage it
5
Q
Aproach to obesity management - second A
A
Assess - assessment of an individual living with obesity using appropriate measurements, identifying the root causes complications and barriers to obesity treatment
- use the 5As identify root cause of weight gain barriers use the edmonton obesity staging system
- Stage 0-1 - does not meet clinical criteria for treatment no or mild symptoms no reason for treatment
- stage 2 - some symtoms and cobidities like T2D some psycological symtoms and moderate functional limitations
stage 3-4 significant or severe obesity related organ damange psychological symotms or functional limitations once you reach stage 4 its usually too laete
6
Q
Approach to obesity management 3rd A
A
- advice - discussion of core treatment options (medical nutrition. therapy and physical activity and adjuctive therapies that may be required including psychological pharmacological and surgical interventions)
- medical nutrition therapy and PA apart of eny one of them but use in combo with adjunctive obesity treatments can be tailored to meet an. individuals health related or weight related outcomes liek oempic which reduces muscle and heart mass so best used if resistence training goes with it
- psychological interventions - behavioral modiciation cognitive behavioral therapy if they do not lose weight need to change the way we thing
- also things like bariatric surgery
7
Q
Approach to obesity management 4th A
A
- Agree - agreement with the person living with obesity regarding goals of therpapy focuing mainly on the value that the person derived from health based interventions
- realistic expectations sustainable goals and personalised actions
8
Q
Approach to obesity managemnt 5th a - Assist
A
- engagement by a health care provider with the individual with obesity in continued follow-up and reassessments and encouragement of advocacy to improve care for this chronic disease - identify and address drivers and barriers to timely followups etc
9
Q
What is success for weight loss
A
- prevention of weight gain
losing weight - maintainng weight - depends on the person
10
Q
What is considered clinically significant wieght loss
A
- losing more than 5 percent of baseline body weight - results in reduction in CVD and T2D factors using diet exercise meds surgery or a combo
11
Q
General guidelines for obesity
A
- the min threshold to prevent weight gain according to ACSM is 150-250 min of PA a week to prevent weight gain greater than 3% ,
- neeed to ensure not too much of an energy imbalance
- resistence training not effective for loss but good for keeping muscle
- can be influenced by outside factors liek social going out getting offered food etc
12
Q
Weight loss vs fat loss
A
- diet leads to a large decrease in body weight and fat mass but also a large decrease in muscle mass not good exercise alone leads to a decrease in body weight, fat mass, and maintenance in muscle but not as much muscle weight loss, so use them combined
13
Q
How is exercise often described -
A
- FIIT and the total ol of PA determines amount of EE with the body weight volume is frequency times time or EE
14
Q
A
15
Q
Incresing EE for weight loss why it would or would not work
A
- would - effect on energy balance is proportional to increse in EE - increse in fat and CHo oxidation woul dbe expected to have favourable health consequences
- would not - achiveable amounts of exercise leads to small increses in EE and adherence to changes in exercise and PA is very poor also incresing EE is linked to a compensatory increse in EI
the most important thing here is what can you adhere to better losing weight this way as you can maintain uscle mass higher with the higher intensity groups but the weight regain was the same so make it easy to adhere to
16
Q
Increasing exercise intensity for weight loss: why would it work or not work
A
Work - same EE in less time, greater imporvements in fitness and other factors, greater preservation of FFM, Decresed appetite -after high intensity exercise, variety and more enjoyable for some
- not work - less enjoyable acceptable, greater risk and safety and less self-efficacy and belief in the ability to perform such activities
17
Q
Incresing exercise intensity for weight loss - best intensity, relative vs absolute fat oxidation, and evidence
A
- low intensity exercise maximized fat oxidation high intensity metabolises primarily CHO use the entensity that leads to highest EE
- proportion metabolised changes as intensity changes relative is the percent of total EE at low intensity fat burning relative greatest at 25 percent max intensity
- absolute - greatest for absolute fat oxidation at 65 percent EE
- evidence - overall vol of activity same for both groups but intensity changed, HIIT loses more weight then moderate due to factors like EPOC endorphin release and evidence the high intenisty decreses appeitete
18
Q
What really matters in terms of weight loss
A
- ahereance to the plan - if you dont do the work nothing wil hapen have to stickl to it can imporve adhereance through things like minimizing costs reducing barriers simplifying plans reminders etc
19
Q
Role of resistence training in weight loss work or not work
A
- increse in muscle mass is the number 1 predictor of function in later life
- work - increse in RMR increses in fat ocidation increse EE increse muscle mass if you have that muscle you wcan walk up stairs stay active for longer incresed TDEE
- not work - effect on FFM is small, effect on FFM during energy restriction is even smaller therefore effect on RMR is not meaningful, energy cost of resistence training is small
- May be more important in some populations like older adults to prevent the FFM loss that comes with dieting to maintain function as once you lose muscle masss when you are older very hard to get it back
20
Q
Exercise for class 2 and 3 obesity why would it work and not work
A
work - contribute to negative energy balance
imporve health and quality of life
improved response to bariatric surgery
- not work
fitness too low to achive eaningful EE
too many comorbidities that coul dbe worsened by exercise like joint pain
time for exercise and fatigue from it could interfere with other activities
21
Q
Why does everyone not respond the same to weight loss and exersice
A
adhereance compensatory behavior and other factors
22
Q
What to consider for class 2 and 3 obeisty patients
A
- access to facilities eqipment
adapted exercise
adated places to sit and changing facilities
23
Q
PA for class 2 and 3 obesity
A
- aerobic activity 30-60 mins for small amounts of body weight and fat loss
- reduction in abdominal viceral fat weight matienence incresed cardio fitness
24
Q
Beyond weight loss what are the advantages of PA
A
- stay functional linger
quality of life imorvements in fat distribution of quality
prevention of weight regain and body comp - low fit individuals have twice teh risk of death
exercise capacity of vo2 max was the storngest predictor of death
increse of 1 met meant an increse of 12 percent in iporvement in survival
doesnt matter how you loose the weight but it does matter how you keep it off to prevent regain
25
Obesity in canada
- epidemic status - childhood obesity has increased substantially
26
Regulation of energy balance
- afferect peripheral hormonal signalliing for orexigenic or apetite inhibiting anoreigenic
2. centeral integration
3. efferent signalliing
4. behavioral change
27
Review of hormones - peripheral appetite regulation
- ghrelin - hunger homrone
PYY - small intesitine - satiety
- GLP1 - small intetine
- CCK - small intestine
PP - pancrease release satitity
all of these are considered episodic hormones, meaning they change from meal to meal, whereas insulin from the pancreas and adipose tissue leptin for satiety are the regulators of overall energy balance and are considered TONIC
28
Not all exercise is the same
- exercise affects appeteite
continoious exercise
- there is a max level you can systain low intensity is considered less than 50 percent vo2 max moderate is 50-70 and vig is more than 70 but unsustainable
interval trianing - 90 percent vo2 all out bouts and can go above your vo2max
29
why would exercise affect appetite
- fatty acids , blood flow, hypoxia oxygen content in blood , SNS , gastrointestinal like fluid in the gut inflammation, blood glucose, alctat
30
Lactate in appetite for acute exercise bouts
- blood lactate goes up significantly in sprinting but not as much in slower speed for same duration
showed that as lactate went up, hunger went down as lactated blunted the release of ghrelin, resulting in exercise-induced appetite suppression and had a small effect with other hormones of PYY and GLP1 but a way bigger effect on ghrelin. It showed that lactate is a mediator males
31
Role of blood glucose on appetite
- not the sam support but still there
- showed glucose fluctuations following exercise could affect appetite and energy intake - high glucose concentration directly suppresses ghrelin secretion in cell cultures but not much done in humans males
32
Role of IL6
- not involved in appetite regulation males
33
Role of Leptin in appetete
- many appetite related hormens may require leptin ro at least leptin receptors to be functional
- may be important for the regulation of energy intake as well as EE
- body rbecomes unresponsive to leptin in times of chornic positive energy balance in incresed adiposity all in males
34
Ovarian hormones and appetite
- menstrual phases
- food intake is normal in the follicular, lower in ovulation slightly, and higher intake in the luteal phase whether you are preg or not, it is hard to determine how it affects appetite
35
Menopause appetite
- low hormonal concentrations of estro and progest
- pre menopausal healthy mid menopausal phase meaning increse in ovarian hormones
and also post menopausal healthy
neither group generated much lactate
what is the min amount of lactate you need to decresed ghrelin
presence of ovarian hormones is also important
min effect on anorexigenic hormones and supports previous work done
36
Exercise interventions on their own
- do not seem to directly lead to desired amoutn fo weioght loss
but imporve cardiovascualr fitness glucose
lots of other things than just purly weight loss
- most important thing for weight loss is diet but do both and in terms of energy balance everything is imporytant peopke may not have the knowledge ability fina cial skills or cooking abilitys to make proper meals
37
Why do we measure body comp
- indicator of health status - excess associated with disease risk
- help favour optimal performance.- sport dependent
- to monitor changes in body comp - growth aging disease
- to evaluate efficacy of treatment - exercise diet drug interventions
38
Definitions - fat mass FFM essential lipids and fats, lean body mass, relative body fat
- fat mass - all extractable lipid from adipose and other tissue in body
- FFM 0 all residual lipid free chemicals and tissues
- essential lipid and fats - compund lipis needed for cell membrane formation
- lean body mass - FFM plus essential lipids
- relative body fat - FM expressed as a percent of total body weight
39
Body comp
- females have higher essential fat mass compared to makles with females being 12 while males is 3
- just like high fat mass the loss of too much fat mass can be detrimental to health
- essential fat is important for organ function
-it's what compartment to measure not just the total amount of proportion but also the location and quality, i.e. visceral at, and the risk of diabetes measured via waist circumference, skin folds, BIA, etc
40
BIA
- chemical approach to measuring body comp
different tissues have differnnct impedance to electrical current more water in tissue means less resistence fat has less water so output percnt body fat and some measure of total body water its inexpensive uses the 2-3 compartment model but has low accuracy validity lots of things interfere with it like low hydration
41
DEXA
- works as radiation passes through body
outputs FM plus FFM plus BM with total and regional FM
the benefits is that its the gold standard non invasive quick reliable 3 compartment model but its expensive large equipment not portable trained technition etc
42
CT - body comp
- works as a anatomical approach roatating x ray of internal structures benefits is that its reliable and valid good for disease management uses 4 compartment model to seperate fat viceral vs subcutaneous but its expensive large trained tech high dose radiation
43
MRI body comp
- works with anatomical approach uses magnets 4 compartemnt model important to disease managemtn like cancer valid reliable no radiation but expensive large requires trained tech and claustrophobia
44
what is the gold standard for measuring viceral fat around organs
- CT and MRI
45
Liposuction body comp
= does not work despite reduction in waist circumference as you are getting rid of subcutaneous fat and not viceral fat so does nothing for disease management
46
BMI body comp
- anatomical approach - weight to heigh ratio kg/msquared benefist is easy low cost tracking tool weakness not appropriate for some populations and tells you nothing about location or quality of weight
47
Waist circumference body comp
- anatomical approach measure circumference of the wasit
fast easy low cost screening or tracking but weakness in that there are large differences between individual vs population indicators
48
Body comp BMI and WC
- can be combined for better risk assumptions
49
waist to hip ratio body comp
- anatomical approach greater than 1 means waist is greater than hips larger number the higher rsk fast easy inexpensive screening and tracking but 2 people with different helath risk can have same waist to hip ratios
50
Body comp quality
- intramuscualr lipids and fat
- - located within skeletal muscle and fibres associated with T2d risk energy stored during exercise decreases in insulin stim not found in athletes the importance of storage depot vs source of energy and development of insulin resistance at the muscle
51
Body comp quality - not all myocytes are the same
- on a 4 month caloric restriction and pa lower BW by 10 percent increse vo2 max increse in mitochondria
- decrese in lipid size
- as lipid droplet size decreased, insulin sensitivity increased as mitochondria size increased insulin sensitivity increased, so this shows there is a role of size vs number
52
Body comp quality - not all adipocytes are the same
- white adipose tissue
- storage insulation protection and packaging endocrine role and inflammtion most commonly talked about - release chemicals and send signals to other organs and releases LEPTIn
- Brown adipose tissues- production of body heat without shivering babies cant shiver imporved insulin reistence and protection against obesity brown color means more capillaried and mitochondria smaller lipid droplets than white adiposutes but lower as you age or lower as the absense of cold exposure found in subcutaneous near clavicales between scapula or viceral like around the blood vessesl and organs such as kidkeys
- Beige adipose tissue -
- brown come from same stem cells as muscle beige or brown like adipocytes
white adipose tissue contains darker adipocytes that come from same precoursaer as WAT near the clavicle or spine but beige has mitocondria so it can produce heat
53
Quality - body comp - adipocyte size matters
- hyperplasia - differentiation from pre adipocytes increse in new cells
hypertrophy - increse in volue or lipid droplet
- decrease in volume for fat loss can decrease the number of hyperplasia that occur in severe obesity from lean to obese individuals
54
quality - body comp - cell death
apoptosis - controlled and mostly non inflammatory cell death
necrosis - cell death involving macrophase recruitment and inflammatory response
- cell death of fat cells in white adipose tissue occurs primarily by necrosis liek cell death
difference os in subcutaneous vs viceral obesity - more macrophase in individuals with viceral obesity leading to more inflammtation - insulin resistence greater T2d risk
55
Medical nurtition therapy - a
- Adherence is the number one factor when chosing a program
- recommend a nondieting approch to imporve QOL physchological outcomes general well being body image perceptions cardiovascular outcomes body weight PA
- move away from dieting culture use for long-term health, physical, and psychological improvements
56
Diet
- the sum of food and drink they habitually consume
- practise of attempting to chive or maintain a certain weight through nutritional intake
- choices are affected by a variety of factors including ethical and religious belifs clinical need money etc
57
Veg diets
- excludes meat and animal produces like gelatin and rennet need to be extra cautious to get protein iron and minerals in
According to the american dietatic association - veg diets are healthful nutrionally adequate and provide health benefits in prevention and treatment of certain diseases
- you can be vegan but only eat junk food
58
Full veg diets
frutarian diet - raw fruit only
Lactoveg diet - certain types of dairy but exclused eggs and rennet food
lactoovo veg - includes eggs and dairy but no animal flesh
vegan diet - contrains only plants and foods made from plants excludes any food derived fro anumals like eggs dairy honey etc
59
Semi veg diets
- flexitarian diet - predominantly veg diet but meat is occasionally consumed
pescetarian diet - a diet which includes fish but not meat
60
Advantages of a veg diet
- lower level of saturated fats
lower consumption of added sugar
low or no consumption of cholesterol
high intake of fibre magnesium potassium folate, antioxidants, phytochemicals
- on average reports lower BMI and lower odds of mortality from heart disease with lower Bp lower cholesertol lower hypertension T2D and certain cancers
61
Disadvantages of veg diets
limiting foods makes getting adequate nurteints difficult
- risk of vitamin b12 deficiency
- inadequate vitamin D consumption if no dairy is consumed which is especially problematic for kids
hard to consume adequate amout of calies think volume wise
- high risk of iron deficiency amnemia so have to monitor intake and increse abosrbption by consuming cirtis juice
risk of protein defiencies plant souces lack certain amino acids
62
Appetite and plant based diets
KETO - used to be very popular and worked very well initially but very bad adhereance to the program and starts with rapid water loss - thikn about dad gained it all back
- in terms of comparing the diets over a 2-week time period, there was a similar amount of weight loss reached, but keto seemed to plateau while veg seemed to keep going this is because there was a difference in the number of calories consumed by themed 600 more calories than in veg diet so over time the veg diet would keto diet consulose more weight more caloric difference even tho there was a similar feeling of hunger satisfaction and weight loss
63
Weight loss and plant based diets
- the role of carbs in weight management is controversial
- vegan group had a greater reduction in weight fat mass viceral fat and insulin sensitivity where the control group had a balanced diet the impact of carb related to the amount of dietary fibre consumed
- showed that veg diets may have greater life improvements across viceral fat loss and insulin sensitivity
- can alos be associated with weight loss becase typically less dense calorically than other foods ie you feel fuller sooner due to volume of food
- comes down to things like candy and processed foods, which are technically veg but high calorie, so food choice
64
Low fat diets
- used to be fat replaced by sugar not its fat replaced by things that are not sugar
- normally defined as about lesss than 30 percent of EI from fat but could also include
less than 10 percent of EI from saturagted fat no trans fat and used to have cholerstol in there but removed it just said to limit that as it could be high in satiurated fats
- low fat diets can also be Ad libidum - meaning you can east as much as you want as long as you keep to low fat
- some studies suggest that low fat intake lead to less obesity
65
Low fat diet why would it work
- density - eating cheese vs vegatible
- efficiency of storing fat as fat in the body is very high
- low thermic effect of feeding from fat
- some people also dont like the taste or texture of fat
- also has a low satiety but not always
66
Low fat diety why is would not work
- palatability - fat tastes good
- high sugar and CHO content
- also evidence that low fat intake leads to incresed obseity think about why - not as oxidised as well eating more other foods
fat can have a high satiety depending on amount of dat and type of fat
- small amounts increse satiety and the more saturated fats you intake the more satieated you feel
- - fatty acid chain length - medium chain are more satiating then long chain
-- also depends on what it's eaten with - fibre CHO and sugar fibrethe most important modifying effects are said to be of all these diets
67
Low fat diet evidence
- studies said 1 percent reduction in fat intake leads to 1.6g fat er day 6 months to 2.9 kg so not rly that beenficial BUt some cases where people enjoy the diet and
68
Low fat diet - jequier bray
- said low fat diet preferred
- metabolic reasons uncouples fat intake and oxidation - dietary fat intake above energy requirements is stored in adipose tissue
- high fat foods or energy dense foods have weak satiety effects and promote overconsumption think volume wise hard to eat 100 cals of ve easy for 100 cals of cheese
- low fat diets are helpful for weight loss and may help with maitenance of weight loss may be associated with type of fat used ie saturated vs unsaturated and better for cardiometabolic health - also good for heart health and certain cancers think dada
69
Low fat diets - negative side effects
- cant rly say what benefits and side effects are due to weight loss or low fat intake
- low palatability - fat tastets good
essential FA vitamins HDL etc
long-term adherence as it is hard to adhere better for prevention of weight gain rather than loss
70
Low card Diet
- some consider it to be less than 20 g CHO a day for 2 weeks then less than 50 g day which is the atkin method which is very hard to follow as you are only getting carbs by accident essentially
- you get ad libidum of dat and animal protein meaning you can eat as much of it as you want
- no universal def for it but in general
- less than 100 g of cards
less than 30% of CHO
- 20-30 pro and 50% fat
71
What are the other definitions of low carb diets
- Low carb diet 20-40% of energy comes from it 30-130g
Very low carb diet 0-20 percent come from CHO less than 30 g also permits metosis to occur where protein appears in the urine idicator of fat burning
- reduced carb diet - more than 130 g CHO per day and up to 45% of total calories
72
Low carb diet - why would it work
- promotes adipose tissue metabolism when CHO absent ie fat metabolism goes up but not as much
- ketones - prodcued when burning fat ie not enough CHO intereacts with incretin hormones CCK and ghrelin to supress appetete ( Increses CCK and Decreses Ghrelin
- rapid weight loss due to appetite supression and water losss as you los 1-2 kg in7-14 days
73
- Low carb diet - ketones
- not rly clear if they work low CHO diets usually have less calories so it coul dbe just that but not known
74
Low carb diet why it would not work
- too restrictuve
low adherence
- concerns with high meat consumption
- discouraging after initial success slows down
- potential for nutritional inadequencies
- potential interference with high amounts of traning ie shown its bad for athletes
- also hard, getting nutrients can and will result in deficiencies
75
Low carb diet - evidence
- nordmann study - 6 month low fat lost more than low carb but at 12 months no difference
low carb better for HDL and TG while low fat was better for LDL and total cholesterol
76
Low carb diet - negative side effects
- less improved in LDL - CHOL vs low fat
- incresed calcium excretion and homosysteine
low energy and bad breath - cancer and other risks
long term adherence low carb has better HDL at 2 years down the line vs low fat
77
Low carb diet - other areas of research -
- showed that low carb diet good for low cardiometabolic health and also better for those predisposed to or already have T2D
- those that have T2d respond to low carb diet way better and more effectivly than those that dont and by the end of treatment they were no longer medically diagnosed with T2D so could be a possible treatment for it
78
High protein diets
- not consistently defined in the literature and are often hard to distinguish from low carb diets
- can be defined relative like more tan 25 percent of kcal from rotein or like more than 1.2g per kg of body weight
79
High protein - why does it work
- high satiety
- energy demanding to store excess protein
- can taste good
- preserve fat free mass
80
High protein - why it would not work
- concerns with high meat ocnsumption
- potentially costly
- high risk of cancer in certain types of meats
81
- high protein evidence
- some studies suggest high protein may be particularlly helpful for prevention of weight regain
- all participants lost 8 percent of body weoight but good for prevention
- evidence is not consistent
- - effect on FFM is small
may require resistence training
FFM is not the same as muscle mass
- most studies look at diet alone
82
High protein - risks
- Similar to low carb
- saftey issues with some protein supplements ie excess protein is hard on kidneys and can contribute to dehydration etc
- health issues with high meat consumption
83
high protein - health issues
- cooking temps high cooking temps of bbq produces carcinogens
- haem iron found in red meat and easy to absorb but non haem is vegtable based protein and is hard for body to process
- 17 percent increase in risk of cancer per 100 g of red meat and 18 percent increase per 50 g per day of processed meat
84
VLCD very low cal diet
- effective 400 kcal day in the past now 800 kcal or less than 50% RMR -
- STRVATION RUINS YOUR RMR AND METABOLISM AND IF DONE WITH HEART ISSUES COULD LEAD TO DEATH OPTIFAST
85
VLCD - who is it for
- no one more but used to be for those with BMI over 30 at risk of CVD with no medical and behavioral contraindications
non pregnant
people who had money
not everyone can adhere
86
VLCD - why could they work
- simple to follow no food prep no calorie counting
large energy deficit
rapid weight loss can be motivating
could be a starting poitn to other changes like exercise
help break eating habits or addictions
87
VLCD - why it would not work
- not a long term solution
- no changes in behavior once its finishes - people will return to old behaviors
- very costly
- must be medically supervised
- not safe
88
VLCD - evidence
- rapid weight loss 25% of initial weight in 3-4 months
89
VLCD - negative side effects
- gallstones in 25 percent of patients
- cold intolerance, hair loss, headaches, huge dizziness, volume depletion, cramps, and constipation
90
Crash or fad diets
- describe diet plans which involve making extreme rapid changes to fod consumption there are many diff types often very low in cals and a deficincy in nutrients
91
What diet to choose
- low-carb diet for anyone with T2D or predisposed to it, and for anyone else, choose the one you can stick to
92
Surgery
- 3 kinds
restrictive
malabsorbtive
mixed procedures
only 1 in about 171 individuals with a BMI of over 35 are eligible
93
Medications
- currently approved
94
Obesity canada report card
- certified bariatric designation is growing
- no oficial guidelines or policies for obesity treatment and management
- lacking interdiciplinary teams in primary care
- patients are expected to cover cost of meal replacements within medically supervised programs around 1000-2000 a month
- medications for obesity are not covered through public drug benefit program
- available to 1 in 171 adults per year, and wait times are up to 8 years for surgery in some cases
95
Bariatric surgery criteria (know well
- performed in individuals with a BMI of 40 or higher OR 35 and higher if its accompanie dby a medical comorbidy like sleep apnea diabetes hypertension and support weight loss
With patients with a BMI of over 40
- strong desire for weight loss
- must understand the impact of surgery
With patients with BMI between 35 and 40 with comorbidies that are known to impove with weight loss
- severe sleep apnea
- severe diabtest
- physical problems interfering with lifestyle
96
Bariatric surgery contraindications to surgery (know well)
- above 60 years of age
- medical condictions makign surgery a high risk
- pregnancy
- genetic conditions like prader willi
- certain menatl health disorders like suicide attempts not iriginally included but added in as we understand the mental strain of the surgeries
- substance abuse or alcohol abuse
- poor attendance or refusal to make lifestyle changes
- unable to comprehend advice
97
Edmonton adult bariatric speciality clinic
- provides medical psychological and surgical interventions for weight management
- initial clinic assessment determines patient specific barriers to weight management help
Need to develop an individualised care plan
- behavior modification
counselling for nutrition PA and mental health
- drug treatment and or bariatric surgery (surgical treatment for obesity)
- assess whether bariatric surgery is an option for clinical patients
98
Procedure types
- sleeve gasteoctomy, gastric banding and others are less effective and invasive than a full gastric bypass
most common documented comborbidities that will be imporved after surgery are like sleep apnea hyptertensive disorders and diabetes melitus hernia
99
Restrictive procedures (surgery)
- restricts the amount of food the stomach can hold
- does not interfere with normal digestion
- makes smaller pouches to hold food
100
Adjustable gastric banding
- restrictive procedure
Advantages
- simple safe short recovery period
major complciation rate is low
- no altering of human anatomy Disadvantages
- more than 5% failue rate because of baloon leakage, band erosion/migration
- deep infection
- slower initial weight loss
- less improvement of diabetes than with bypass
101
Sleeve gastrectomy
- restrictive procedure
Advantages
- no insertion of foreign objects
Reduces food intake (removes ghrelin cell mass - lowers hunger)
- no malabsorption of nutrients
- low potential for leakage
Disadvantages
- irreversible
inadequate weight loss/gain (stretch)
- stomach can stretch back almost to normal size with excess consumption
- complications are rare but can be very bad
102
Malabsorptive procedures
- Combines stomach restriction with a partial bypass of the small intestine
- reduces the amount of calores and nutrients the body absorbs
103
Roux-en-Y Gastric bypass
- a small pouch created to restrict food intake
- A shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum and the first portion of the jejunum
Advantages
- Significant weight loss
- control food intake
reversible in emergency
minimal diet restriction
Disadvantages
-Stabple line failue
- ulcers
- narrowing/blockage of the stoma
- vomiting if the food is not properly chewed or eaten too quickly
rick of deficiencies in vitamins (B12) iron, calcium
Dumping syndrome
- when sugary food is ingested, it could leave the stomach quickly, causing intestine swelling, cramping and pain, other symptoms too
104
Potential complications of abdominal surgery
- infection
- hemorrhage
- hernia
- bowel obstruction
- anastomotic leakage (leak where bowels are joined)
- dumping syndrome
- nutritional deficiencies
- increased risk of death in first 3 months (including increased risk of suicide
105
Diabetes remission
Partial
- A1C less than 6.5%
- at least 1 year duration
- no hypoglycemic agents (medication)
Complete
- A1C less than 5.7
- At least 1 year duration
- no hypoglycemic agents (medication)
Prolonged
- A1C less than 5.7 percent
- at least 5 year duration
- no hypoglycemic agents (medication
106
What is most effective for diametes remission
- metabolic surgery more effective than medical/lifestyle interventions
107
Mechanisms for diabetes remission with metabolic surgery
- initially, improvement of hepatic insulin sensitivity independent of the weight lost
- improvement in beta cell production/ function as blood glucose levels are coming down
- improvement in peripheral insulin sensitivity due to reduced adipose tissue
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Mechanisms for diabetes remission with metabolic surgery - weight independent glucose lowering mechanisms
- favourable changes in gut hormone GLP1
- incresed glucose metabolism by small intestine
- possible alterations in gut microbiota
- in obese most medications had minimal effect on systolic and diastolic BP with less than 5mmHG
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Medications for weight loss are for who?
BMI over 30
Or BMI over 27 with comorbidies of thinsg like CVD diabetes sleep apnea etc
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Orlistat
- medication
- Lipase inhibitor - fat passes directly through the digestive system
- side effects - uncontrolled bowel movements
- has small effect on diabetes/ HTN
- not substantial weight loss
- not much adherence
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Contrave
-medication
- naltrexone and bupropion, work toegther on different parts of the brain to control eating (hunger and cravings)
This is approved alongside a reduced calorie diet and increases PA for patients with a BMI of 30 or over or 27 and over with comorbidity
- fairly effecive
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Semaglutide (ozempic)
- most effective
- Benefits outweigh the risks , more adhereance
-
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Saxenda - liraglutide
- GLP1 - slows gastric emptying more side effects the higher the dose
- 1.2-1.8 for diabetes treatment and 3 mg for weight loss
side fx
- nausea headache dizziness potentially thyroid cancer - this is why some people want it off the market
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Psycological effects of surgery
- greive loss of food
- incresed self esteem and self confidence or decrese
- changes in social circles
- difficulty with social and buisness functions that revolve around food
- resentment to suddenly improved social acceptance
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What type of support would someone need getting bariatric surgery
- pre and post care
- psychological care (VERY important)
- nutrition
- exercise
- skin flap surgery
- need to stop the underlying cause addiction eating habits or trauma otherwise wont be very effective in the long term
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Result of surgerys
- 40% reduction in mortality high decrese in incidence of diabetees coronary artery disease and cancer
- banding is leaste effective but there is still a drop overall so all of these can be effectove and life changing however the weight is only one aspect again need to adress underlying cause
- diabetes surgery should be considered for pateints with inadequatly controlled diabetes and a BMI as low as 30 or 27.5
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KIN 334
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