1
Q
What’s the two treatment phases of obesity?
A
Induction of weight loss through caloric restriction and prevention of weight regain
2
Q
Which classes of drugs are associated with weight gain?
A
- Antidepressants
- Tricyclic antidepressants
- Amitriptyline - Antipsychotics
- Corticosteroids (prednisone)
- Antihyperglycemic drugs (sulfonylureas, meglitinides, thiazolidinediones, insulin)
- Lithium (for mania)
3
Q
Would discontinuation of anti-obesity medication result in weight regain?
A
Yes
4
Q
What’s the approved appetite suppressants in Canada?
A
Bupropion/Naltrexone
Bupropion:
- a sympathomimetic drug
- given as a sustained-release formula
- used as an antidepressant and smoking cessation aid
5
Q
Which population is bupropion/naltrexone indicated for?
A
BMI of 30+ or BMI of 27 with weight-related comorbidity
plus weight management alongside diet and exercise
6
Q
What are the adverse effect of bupropion?
A
Dry mouth
Constipation
Agitation
Insomnia
Anxiety
Seizures (if higher doses. Rare)
7
Q
What should we be careful of when prescribing bupropion?
A
Caution in patients with hepatic impairment
8
Q
What are the adverse effects of a combination of bupropion/naltrexone?
A
Nausea, vomiting, constipation, headache, dizziness, insomnia, dry mouth
9
Q
What is the contraindication of a combination of bupropion/naltrexone
A
Contraindicated with concurrent opioid therapy (due to precipitation of opioid withdrawal)
10
Q
Before initiating a combination of bupropion/naltrexone, what should the patient do? (opioid -wise)
A
Patients must be opioid free for 7 days
11
Q
What are the cautions for starting bupropion plus naltrexone?
A
- Avoid concurrent use of drugs that lower the seizure threshold
- Minimize or avoid alcohol consumption
- Avoid consumption with a high-fat meal
- Avoid in patients with uncontrolled hypertension, seizure disorder, severe hepatic impairment, or end-stage renal failure.
12
Q
What is orlistat?
A
Pancreatic and gastric lipase inhibitor which reduce dietary fat absorption by 30%.
13
Q
What are the adverse effects of orlistat?
A
- Oily spotting, flatus with discharge, fecal urgency.
- Decreased absorption of fat-soluble vitamins
14
Q
What is the contraindication for orlistat?
A
It is contraindicated in patients with chronic malabsorption syndrome or cholestasis.
15
Q
What are the cautions for orlistat?
A
- Advise patients to take a multivitamin daily ≥2 h before or after orlistat or at bedtime 2. A high fat intake is poorly tolerated
- Less effective in patients on low-fat diets and is difficult to take for individuals with irregular eating patterns
16
Q
What is liraglutide, what is it indicated for and how is it administered?
A
Liraglutide is GLP-1 agonist (incretin mimetics). Originally it is for type 2 diabetes and then rebranded for obesity. It is administered by subcutaneous injection.
17
Q
What are the adverse effects of liraglutide?
A
- Most common: nausea, vomiting, constipation, diarrhea.
- Gastrointestinal side effects can be minimized by a slow titration.
- pancreatitis (rare)
- Severe hypoglycemia observed in patients with type 2 diabetes (adjustment of diabetes medications may be required)
18
Q
What are the cautions of liraglutide?
A
Caution in patients with heart rhythm disturbances, hepatic insufficiency, and severe renal impairment. Should not be used in IBD.
19
Q
What is the contraindication of liraglutide?
A
Contraindicated in pregnancy, breastfeeding, personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2 (MEN 2).
20
Q
Under which circumstance, should a patient discontinue liraglutide?
A
Discontinue after 12 weeks if body weight loss <5%
21
Q
What is semaglutide and how is it administered?
A
GLP-1 agonist like liraglutide but with a longer half-life. It is administered by weekly subcutaneous injection.
22
Q
What are the adverse effects of semaglutide?
A
Similar to liraglutide.
- Nausea, diarrhea, abdominal pain, vomiting, constipation, digestive upset, fatigue, dizziness.
2. Increase in amylase and lipase, suggesting possible pancreatitis.
23
Q
What is obesity during pregnancy associated with?
A
- Gestational diabetes
- Gestational hypertension
- Preeclampsia
- Birth defects
- Caesarean delivery
- Fetal macrosomia
- Perinatal deaths
- Postpartum anemia
- Childhood obesity in offspring
- Longer labor
- Increased risk of complications following caesarean delivery
24
Q
Despite the increased risks, is weight loss during pregnancy recommended?
A
No
25
What should pregnant women with obesity do?
Counsel regarding weight gain targets (to gain no more than 5 – 9.1 kg (11 – 20 lb) during pregnancy).
26
Why orlistat is specifically not recommended during pregnancy?
Due to reduced fat-soluble vitamin absorption
27
If a pregnant patient with obesity is already taking bupropion, should it be withheld for continuation of therapy ?
No
28
Liraglutide, Orlistat, Bupropion and Semaglutide. Which medications is expected to cause the greatest amount of weight loss?
Answer: Semaglutide
Liraglutide (8kg weight loss over 2 years)
Orlistat (2.9% weight loss over a year)
Bupropion (2.2% - 5.1% weight loss)
Semaglutide (16kg over 2 years)
29
Does the risk factors for insulin resistance also apply to NAFLD?
Yes
30
What are the foundational interventions for NALFD?
Diet and lifestyle counselling
31
Which two factors increase the risk of NAFLD?
Obesity and sedentary lifestyles
32
What is the common body fuel for oxidation and is found in blood and tissue fluids and metabolized in most body tissues?
Glucose
33
Most complex carbohydrates are digested/converted into units of what for fuel?
Units of glucose
34
What is sucrose made of?
Glucose + fructose
35
What is lactose made of ?
glucose + galactose
36
What is maltose made of ?
Glucose + glucose
37
Is galactose found as a monosaccharide in foods?
No. Galactose is bound to glucose to form the disaccharide lactose.
38
How is galactose used as fuel?
Converted to glucose in the liver through a reversible process.
39
During lactation, what is converted to galactose?
Glucose
40
What is a common constituent in glycolipids and glycoproteins?
Galactose
41
What is the dietary sources of galactose?
Dietary sources include anything with lactose (dairy foods, etc.)
42
Is fructose the sweetest simple sugars?
Yes
43
What is fructose converted to in the liver and intestine?
Glucose
44
Does transport and metabolism of fructose require insulin?
No
45
Does the body have a lot capacity to metabolize fructose?
No. Only a few tissues have the capacity to metabolize fructose (liver, intestine, kidney, adipose and muscle tissue)
46
What is fructose ended up doing in the liver?
Fructose usually ends up replacing liver glycogen or being used in the synthesis of triglycerides.
46
Where is the vast majority of fructose metabolized in the body?
Liver
47
Which transporters is the majority of ingested fructose passively absorbed by?
GLUT5 transporters
48
How do high fructose diets amplify absorption?
High fructose diets can amplify absorption by upregulating additional transport mechanisms.
49
Is processing of fructose in the liver controlled by hormone or allosteric mechanisms ?
No. There is no rate-limiting step like there is with glycolysis.
50
Do metabolic changes act as feedback inhibitors to fructose metabolism as they do with glycolysis?
No
51
Which pathway do excess metabolites (like pyruvate) enter?
Various other pathways such as fatty acid synthesis and cholesterol
52
What is the dietary sources of fructose?
Naturally found in fruit and some vegetables, honey, agave nectar/syrup.
53
What are some high-fructose corn syrup ?
Sugar-sweetened beverage
Processed foods
“Added” sugar
54
What is longer chains of glucose units called?
Polysaccharides
55
What is smaller chains of 3 – 10 glucose units called?
Oligosaccharides
56
What is the storage form of carbohydrates in plants?
Starch
57
What is the storage form of carbohydrates in animal?
Glycogen
58
Can all polysaccharides to digested?
No. we refer the undigested one as dietary fiber.
59
Do general recommendations that prevent obesity also prevent NAFLD?
Yes
60
What are some therapeutic considerations for NAFLD?
Avoiding additional damage to the liver
- Avoiding/abstaining from alcohol consumption
- Mindful of other therapeutics that can harm the liver
Recognizing other risk factors or conditions
- NAFLD is often found in patients with other conditions like diabetes, obesity, hypertension, etc.
61
What are some basic therapeutic considerations for NAFLD?
Avoiding excess sugar/carbohydrate consumption, especially fructose
Reducing saturated/trans fat intake
Opting for lean proteins and increasing vegetable consumption
EXERCISE
62
wk2 nutrition lecture page 22 for medi diet guidance....
63
What is the best diet for preventing and treating NAFLD?
Mediterranean diet for both prevention and treatment
A general low-concentrated carbohydrate diet (Depending on other comorbidities, poorly managed diabetes, for example)
64
Which of the following dietary recommendations is consistent with the Mediterranean diet?
A. Three servings or more of red meat per week
B. Three or more servings of legumes per week
C. One daily serving of white wine
D. Less than four tablespoons of olive oil per wee
B. Three or more servings of legumes per week
65
What does CLEMS refer to in homeopathy?
C: Concomitants (associated symptoms)
L: location
E: Etiology
M: Modality
S: Sensation
66
This patient came in with chief complain of vertigo. He is a charming person with magnetic appeal. He has enlarged liver, elevated enzymes and had polyps in bowels (removed). He has foggy vision which would occur in stressful situations, for example, in situations where he had to talk in front of an audience and all of a sudden, he could not see properly. He liked to drink alcohol: wine, beer, in large quantities. He emptied a glass in one sip. (page 25 of wk3 HOM for CLEMS)
Phosphorus
67
What are the toxicity of phosphor?
1. Irritation: mucus membranes...
2. Inflammation: serous membranes, spinal cord and nerves
3. Degeneration or destroy: bones, especially lower jaw and tibia
4. Fatty degeneration
- blood vessels and tissues
- organs of the body
5. Increasing hemorrhage
6. Sub-acute hepatitis
7. Great susceptibility to external impressions (light, sound, odors, touch...)
68
The characteristics of this remedy is sympathetic, sensitive, social, stimulated easily and fearful at the same time. What is this remedy?
Phosphorus
69
This remedy is for acute hepatitis, pulmonary disease or severe infectious syndromes. What is this remedy?
Phosphorus
70
The characteristics of this remedy is:
1. restless, constant motion, nervousness
2. frequent burning or heat sensation in stomach and liver
3. Hemorrhage: nose bleeds with profuse flow
4. weakness (prostration and debility)
5. crave for cold drinks (icy cold water, refreshing juicy food, ice cream).
Phosphorus
71
With the characteristics of this remedy, symptoms get worse with touch, physical or mental exertion, warm food or drink, twilight, change of weather and during a thunderstorm. What is this remedy ?
Phosphorus
72
With the characteristics of this remedy, symptoms get better with cold (cold food, cold, open air, washing with cold water) and get better with sleep. What is this remedy ?
Phosphorus
73
With the characteristics of this remedy, patient has pneumonia (left lower lobe) or laryngitis from talking, singing, with pain (dry, raw, sore throat) or liver disease or intend to prophylactic against viral hepatitis or have fatty degeneration, tumors, growths, caries or nausea/vomiting from hot drinks, as water is thrown up as soon as it gets warm in the stomach or post-operative vomiting. What is this remedy ?
Phosphorus
74
This patient is tall and slender, with narrow chested, thin & transparent skin, weakened by loss of animal fluids, with great nervous debility, emaciation, amative tendencies. What remedy should be given to this patient?
Phosphorus
75
What is the toxicity of potassium bichromate? (acute & chronic)
Acute:
1. Gastroenteritis followed by collapse
2. Acute tubular nephritis and hepatitis
Chronic:
1. Mucosal lesions (thick adhesive lesions)
2. Cutaneous lesions (allergic contact eczema)
76
What are the affinities of kali bichromate?
1. Mucous membranes: stomach, bowels, airways (including sinuses)
2. Bones and fibrous tissue
3. Kidneys
4. Heart
5. Liver (Cirrhosis of liver)
77
This patient is indifferent, indolent and averse to mental and physical exertion. He avoids human society, anthropophobia (fear of people), has weakness of memory (i.e. dates) and has frequent vanishing of thoughts. What remedy is it?
Kali bichromate
78
This patient has pains that occur in small spots or migrate quickly from place to place. The pains appear and disappear suddenly or the disease conditions progress slowly but deeply. What remedy should be given?
Kali bichromate
79
Symptoms such as:
1. greenish, thick, STICKY, stringy, lumpy discharge.
2. Chronic inflammation of frontal sinus with stopped up sensation
3. Coryza with obstruction of nose
4. Rheumatic and gastric symptoms alternate
5. Fatty infiltration of liver and increase in soft fibrous tissue.
are characteristic of this remedy. What is it?
Kali bichromate
80
Patient feel better from heat but the symptoms get worse with beer (cravings)/morning/cold/wet weather/hot weather/undressing. What remedy should be given?
Kali bichromate
81
What are the key actions in botanicals for NAFLD treatment?
Alterative. Hepatic
82
What is the overall flavor of your formula for NALFD should be ?
Bitter and cool.
83
What will be the thrust of your treatment plan for NALFD?
Food and exercise
84
If what condition is present in NAFLD, we should treat that condition primarily?
Constipation
85
In the case of NAFLD, what are the primary botanical action/secondary or supportive/others should we consider?
Primary: hepatic, bitter
Secondary/supportive: hepatoprotective
Others: carminative, laxative
86
In the case of NAFLD, what are the herbs selection for 'HEPATIC' action?
Barberry (Berberis vulgaris)
Yellow dock (Rumex crispus)
Peony (Paeonia lactiflora)
Bupleurum (Bupleurum sinensis)
Burdock (Arctium lappa)
Gentian (Gentian lutea)
Sweet wormwood (Artemesia annua)
Andrographis (Andrograpis paniculata)
Schisandra (Schisandra sinensis)
87
In the case of NAFLD, what are the herbs selection for 'HEPATOPROTECTIVE' action?
Milk thistle (Silybum marianum)
Schisandra (Schisandra sinensis)
88
In the case of NAFLD, what are the herbs selection for 'HEPARIC+LACATIVE' action?
Burdock (Arctium lappa)
Yellow dock (Rumex crispus)
89
In the case of NAFLD, what are the herbs selection for 'CARMINATIVE + HEPATIC' action?
Gentian (Gentiana lutea)
Yarrow (Achillea millefolia)
Archangelica (Angelica archangelica)
Sweet wormood (Art. annua)
90
For herb-drug interaction, what does berberis vulgaris do to diabetes medications?
Berberis vulgaris may augment the effect of diabetes medications.
91
In uncomplicated cases of NAFLD, which two interventions are needed most?
Diet and exercise
92
In the cases of NAFLD, what are the main aggravating foods?
Sugar, Dairy, and alcohol, as well as fried foods.
93
What are the primary actions of arctium lappa and which condition should it be indicated to use?
Arctium lappa (burdock) in the case of NAFLD.
Primary actions: Alterative (Hepatic, mild laxative, nutritive)
** Pairs well with Zingiber officinalis for nausea of deficient stomach.
94
What are the primary actions of berberis vulgaris and which condition should it be indicated to use?
Berberis vulgaris (Barberry) in the case of NAFLD.
Primary actions: Antimicrobial (potent), excellent hepatic, alterative (during and post-infection and useful in stimulating digestion), cholagogue, bitter, anti-inflammatory, endocrine modulator (insulin)
**Pairs Well With:
Bupleurum sinensis in hepatic infections
Galega officinalis in type II diabetes
Chelidonium majus and Peumus boldo in addressing gallstones.
95
What is the contraindication in using berberis vulgaris?
Avoid during pregnancy and lactation
96
What are the primary actions of gentiana lutea and which condition should it be indicated to use?
Gentiana lutea (Gentian) in the case of NAFLD.
Primary Actions: Bitter (potent and effective to improve digestion), silagogue, hepatic.
**Pairs well with Archangelica and Zanthoxylum americanum for toning the stomach.
Indications:
1. Sluggish digestion
2. Low appetite
3. Constipation
4. Bloating
97
Under which condition, should we not use Gentiana lutea?
Not to be used in cases of known ulceration.
98
What are the primary actions of bupleurum sinensis and which condition should it be indicated to use?
Bupleurum sinensis (bupleurum) is used in the case of NALFD.
Its primary actions are:
Hepatic
Alterative (Excellent hepatic alterative for long-standing inflammation from physical or emotional accumulation)
Anti-inflammatory ( hepatitis )
Hepatoprotective ( hepatitis )
**Pairs Well With:
Inflammation (expecially joints):
Berberis vulgaris
Uncaria tomentosa
Harpagophytum procumbens
Stagnant menses with heat presentation:
Paeonia alba
99
Under which conditions, should we avoid the use of bupleurum sinensis?
Avoid in cold conditions or constitutions
100
What are the primary actions of Paeonia lactiflora and which condition should it be indicated to use?
Paeonia lactiflora (Peony) in the case of NAFLD.
Primary Actions
Female endocrine modulator
Alterative
Antispasmodic
Mild adaptogen
Mild anti-inflammatory
Emmenagogue
Nootropic
**Any condition of female hormone dysregulation, fertility challenges, acne
** TCM:
1. cool the liver and support smooth flow
2. in dysmenorrhea and other female hormone patterns of both deficiency and excess.
3. pair with glycyrrhiza glabra as a classic TCM formula for dysmenorrhea and PCOS.
101
What herb-drug interaction should we pay attention when using Paeonia lactiflora?
Possible interaction with anticoagulants.
101
What are the primary action for Rumex crispus and under which condition would you use it?
The primary actions for Rumex crispus (Yellow dock)are :
1. Alterative (Strong and effective, also useful in building the blood)
2.Laxative (mild)
3. Hepatic
4. Astringent
5. Mild adaptogen
Condition (case of NAFLD)
1. Chronic skin conditions
2. Constipation
3. Convalescence.
Pairs Well With:
Chronic skin conditions:
Berberis vulgaris
Convalescent adaptogen:
Inonotus obliquus
Smilax officinalis
Polygonum multiform
102
What are the cautions of using Rumex crispus?
Not to be eaten fresh, potentiates other stimulating laxatives.
103
What are the primary actions of Schisandra sinensis and under which condition would you use it?
Primary actions of Schisandra sinensis (Schisandra), in the case of NAFLD:
1. Adaptogen
2. Astringent
3. Hepatoprotective (In ongoing toxic exposure or hepatitis )
4. Alterative
5. Expectorant
6. Nervine
7. Parturient.
*8. Excellent tonic, particularly for the feminine aspect.
Pair with:
Paeonia alba
*In female hormone patterns in need of tonification and rooting, where there are unprocessed emotions of sadness and poorly defined boundaries.
Ephedra sinica
*In chronic deficient cough with thin, clear mucus.
Silybum marianum
Bupleurum sinensis
*Hepatoprotective formulas for ongoing toxic exposure or hepatitis.
104
What are the cautions of suing schisandra sinensis?
Mild uterine stimulant.
105
What is the recommended level of water intake?
Half of the body weight in ounces
NMT200
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