obesity

Question 1

Obesity

What is obesity?

Answer 1

Multifactorial disease with physical, psychological and social consequences. Defined as BMI ≥ 30kg/m2. In children, it is defined as those ≥ 95th percentile (WHO growth charts).

Question 2

Obesity

Obesity age and prevalence

Answer 2

Children 18.4%

Adults 39.8%

Question 3

Obesity

Obesity risk/etiologies

Answer 3

• Imbalance between energy intake and energy output
• Genetics (e.g., Prader–Willi syndrome)
• Medical conditions (e.g., Cushing’s syndrome, polycystic ovary syndrome [PCOS])
• Age
• Pregnancy
• Environmental factors
• Drug-induced obesity:
  • Antidepressants (amitriptyline, doxepin, imipramine, mirtazapine, nortriptyline, paroxetine, phenelzine)
  • Antihistamines (cyproheptadine)
  • Antipsychotics (clozapine, haloperidol, olanzapine, quetiapine, risperidone, thioridazine)
  • Antidiabetics (insulin, sulfonylureas, thiazolidinediones
  • Anticonvulsants (sodium valproate, carbamazepine, gabapentin)
• Steroids (contraceptives, glucocorticoids, progestational steroids)
• Beta- or alpha-adrenergic blockers (propranolol, doxazosin)
• Glucocorticoid steroids
• Sleep disturbance–induced obesity
• Quitting smoking

Question 4

Obesity

Subjective data for obesity

Answer 4

· Onset of weight gain, rapid/gradual? 
· Symptoms 2nd obesity (see S&S) 
· 24 hour diet recall
· Review: fast food, high-calorie drinks, alcohol intake 
· Review timing and frequency of meals (nighttime eating?)
· Screen for disordered eating 
· Weight loss attempts
· Sleep, daytime fatigue, snoring 
· Screen for depression 
· Assess readiness for weight loss 
· Screen time
· Physical activity 
· Possible related events (stress, new med, menopause, smoking cessation, etc) 
· Functional assessment

Question 5

Obesity

physical exam for obesity

Answer 5

• Inspect 
	- Vitals (C&G says postural vitals??)
	- BMI
	- Waist to hip ratio 
	- Neck circumference (if concerned re: OSA) 
	- Overall appearance, fat distribution 
• Auscultate:
	- Heart, lungs, carotid arteries, abdomen
• Palpate neck
thyroid, extremities (edema?), abdomen

Question 6

Obesity

What are some commonly associated symptoms/conditions/complications?

Answer 6

• Difficulties with activities of daily living (ADLs) or functional impairment
• Decreased exercise tolerance
• Asthma exacerbations
• Difficulty with personal hygiene
• Urinary incontinence
• Decreased quality of life (e.g., depression, disability, shame and guilt, social isolation)
• OSA
• Infertility/PCOS
• Cholelithiasis
• OA
• Metabolic syndrome & NAFLD
• HTN, CVS disease & dyslipidemia
• Cancer (colon, endometrial, lung)

Question 7

Obesity

Investigation for obesity

Answer 7

TSH, lipid panel, liver enzymes, CBC, FPG, Hgb A1C, fasting insulin level?, sleep studies/nocturnal hypoxemia study, workup for PCOS?

Question 8

Obesity

weight loss goals

Answer 8

• Weight loss of 5-15% can provide significant reduction in obesity-related complications

Question 9

Obesity

when to refer for bariatric surgery?

Answer 9

Consider referral for bariatric surgery if BMI > 40 or 35 with CV comorbidities

Question 10

Obesity

non-pharm tx for obesity

Answer 10

• Treatment should be individualized and patient-centred
• Behaviour therapy
• Diets shown to be effective include portion control, low-fat, Mediterranean, low-carbohydrate, low glycemic index, etc…
• Increase water intake, particularly drinking 500 mL of water before meals.
• Protein-dense and high-fiber foods increase satiety with fewer calories.
• Children 6 to 17yrs: Recommend 60 min or more moderate to vigorous exercise/day (155 to 180 min/week)
• Adults:
  • Even single episodes of physical activity are helpful! Every bit counts!
  • Physical activity can also improve: memory, processing speed, attention, lower BP, improve cholesterol, lower A1C, strengthens bones, improves mental health, boosts immunity, reduces stress, improves joint pain, improves sleep, improves functions (ADLs and i-ADLs)
  • 150 min moderate intensity exercise/week
  • Multiple short sessions (4X10 min sessions X 5 days) may have same benefit as longer sessions (one 40 min session X 5 days)
• Weight training 2X/week helpful

Question 11

Obesity

Pharm options for weight reduction and contraindications

Answer 11

orlistat (Xenical)
- cholestasis, chronic malabsorption syndrome, pregnancy

Liraglutide (GLP-1, Saxenda)

• • very effective, expensive, good for blood glucose, subcut injection
• pancreatitis, thyroid CA, pregnancy

Naltrexone/bupropion (Contrave)

• uncontrolled HTN
• opioid use
• seizures (risk or hx)
• ETOH withdrawal
• MAOI
• renal or hepatic failure
• pregnancy