CMS200 obesity

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Questions and Answers

What is the impact of insufficient sleep on weight management?

It is associated with increased appetite and caloric intake. (correct)

It decreases overall caloric intake.

It has no significant effect on weight.

It contributes to a faster metabolism.

Which factor is NOT considered an environmental factor contributing to obesity?

Abundant food supplies in an obesogenic environment.

Personal dietary choices influenced by health education. (correct)

Prolonged TV watching as part of a sedentary lifestyle.

Mobility issues due to physical disabilities.

What relationship exists between socioeconomic status and obesity prevalence?

Socioeconomic status has no effect on obesity prevalence.

Lower income correlates with higher obesity rates. (correct)

Higher income correlates with higher obesity rates.

Obesity is uniformly distributed across all income levels.

Which group has been found to experience higher levels of body dissatisfaction?

White women compared to Black and Hispanic women. Signup and view all the answers

What is the role of alcohol consumption in weight gain?

It contributes to weight gain through liquid calories. Signup and view all the answers

What is the most common cause of primary weight gain?

Imbalance between caloric intake and energy expenditure Signup and view all the answers

Which factor should NOT be assessed during patient intake for obesity?

Daily water intake Signup and view all the answers

What laboratory screening is essential for comorbid conditions in patients?

Comprehensive metabolic profile Signup and view all the answers

At what age range is weight gain typically highest among adults?

24-34 years Signup and view all the answers

What psychosocial factor should be assessed during patient intake for obesity?

Assessment for mood and eating disorders Signup and view all the answers

What is a likely environmental factor contributing to weight gain?

Higher consumption of refined grains, sugar, and fats Signup and view all the answers

Which demographic trend indicates a tendency for weight loss?

Adults after 55 years Signup and view all the answers

What should be considered a significant risk factor when evaluating primary weight gain?

Rapid weight increase Signup and view all the answers

What percentage of patients with type 2 diabetes mellitus (T2DM) are also classified as obese?

80% Signup and view all the answers

Which risk factor is NOT associated with an increased likelihood of developing obstructive sleep apnea (OSA)?

Low socioeconomic status Signup and view all the answers

Which of the following symptoms is most commonly associated with type 2 diabetes mellitus (T2DM)?

Fatigue Signup and view all the answers

What is the primary method used to diagnose obstructive sleep apnea (OSA)?

Polysomnography Signup and view all the answers

Which of the following is a characteristic feature of non-alcoholic fatty liver disease (NAFLD)?

Presence of hepatic steatosis without secondary causes Signup and view all the answers

Which screening tool is validated for assessing the risk of obstructive sleep apnea (OSA)?

STOP-Bang questionnaire Signup and view all the answers

Which of the following statements about the prognosis of non-alcoholic fatty liver disease (NAFLD) is accurate?

NAFLD can lead to significant liver complications if untreated. Signup and view all the answers

When diagnosing T2DM, which of the following is an acceptable fasting blood glucose (FBG) level indicative of diabetes?

7.0 mmol/L Signup and view all the answers

What is a common consequence of untreated obstructive sleep apnea (OSA)?

Decreased overall life expectancy Signup and view all the answers

Which of the following measures is NOT a component of the STOP-Bang questionnaire?

Heart rate Signup and view all the answers

Which bariatric procedure requires bone densitometry every 2 years during follow-up?

Roux-en-Y Gastric Bypass (RYGB) Signup and view all the answers

How often should vitamin B12 levels be monitored postoperatively in patients undergoing LAGB, LSG, RYGB, or BPD/BPD-DS?

Every 3-6 months if supplemented Signup and view all the answers

Which laboratory evaluation is performed at each follow-up visit for all bariatric surgery procedures?

Complete Blood Count (CBC) and Chemistry Panel Signup and view all the answers

Which of the following vitamins is exempt from yearly monitoring in LAGB and LSG procedures?

Copper Signup and view all the answers

What is the recommended follow-up interval after achieving stability for RYGB patients?

12 months Signup and view all the answers

During follow-up, which procedure monitors both copper and zinc levels?

Roux-en-Y Gastric Bypass (RYGB) Signup and view all the answers

What is the primary focus of the 5As framework in obesity management?

Determining readiness for lifestyle change Signup and view all the answers

What is the frequency requirement for lipid evaluation after bariatric surgery?

Every 6-12 months Signup and view all the answers

Which of the following symptoms is NOT considered a red flag finding for obesity complications?

Fatigue after minimal activity Signup and view all the answers

What is the BMI classification for someone with a BMI of 36?

Obesity Class II Signup and view all the answers

What percentage of breast cancer prevalence is attributed to obesity?

11% Signup and view all the answers

Which condition has the highest prevalence among the serious comorbid diseases in the obese population?

Non-alcoholic fatty liver disease Signup and view all the answers

Among the following diseases, which one has the lowest proportion of prevalence attributable to obesity?

Colon cancer Signup and view all the answers

What is a common complication of obstructive sleep apnea related to obesity?

Fatigue during the day Signup and view all the answers

Which of the following risk factors has an age-adjusted relative risk of 2.75 for hypertension in females with a BMI ≥ 30?

Obesity Signup and view all the answers

Which class of obesity corresponds to a BMI of 29.8?

Overweight Signup and view all the answers

Which of the following conditions is listed as a comorbidity due to obesity and involves joint pain?

Osteoarthritis Signup and view all the answers

Chest tightness and pressure during emotional stress are indicative of which potential comorbidity?

Coronary artery disease Signup and view all the answers

What is the relative risk for diabetes mellitus in males with a BMI of ≥ 30?

2.12 Signup and view all the answers

Which obesity-related disease has a prevalence of 49 - 65% in the population?

Hypertension Signup and view all the answers

How is the classification of obesity determined?

Body Mass Index and waist circumference Signup and view all the answers

Which of the following is NOT typically categorized as a comorbidity of obesity?

Improved athletic performance Signup and view all the answers

Study Notes

Medical History

Determine age of onset of weight gain
Note recent weight changes, especially rapid gain
Assess family history of obesity, as this may be a genetic predisposition
Explore occupational history, as some occupations may contribute to weight gain
Evaluate eating and exercise habits
Inquire about previous weight loss attempts, including reasons why they may have been unsuccessful
Assess psychosocial factors, including mood disorders and potential eating disorders

Primary Weight Gain

Most common cause of weight gain, with women being more likely to gain weight than men
Peaks between ages 24-34, with individuals over 55 years old more likely to lose weight
Primary weight gain is due to an imbalance between caloric intake and energy expenditure
Increased caloric intake is influenced by:
- Increased appetite
- Reduced physical activity levels
- Reduced basal metabolic rate (BMR)
- Reduced thermic effect of food

Environmental Factors Contributing to Weight Gain

Increased Caloric Intake:
- High consumption of refined grains, added sugars, and fats (e.g., processed and fast foods) is strongly associated with obesity.
Eating Patterns:
- Binge eating and night eating disorders can contribute to obesity.
Alcohol Consumption:
- Intake of "liquid calories," specifically heavy alcohol consumption, is associated with weight gain and obesity.
Insufficient Sleep:
- Associated with increased appetite and caloric intake.
Smoking Cessation:
- Can lead to an increased caloric intake and reduced energy expenditure, contributing to weight gain.
Sedentary Lifestyle:
- Prolonged television watching is associated with an increased risk of obesity, primarily due to a reduction in energy expenditure. This lifestyle choice also increases the risk of chronic diseases and overall mortality.
Physical Disability:
- Mobility problems can alter body composition and decrease energy expenditure, including limiting physical activity. This can lead to a higher prevalence of obesity.
Obesogenic Environment:
- Abundant food supplies, eating for pleasure and entertainment (rather than nutritional needs), and urban sprawl that discourages walkability are all obesogenic factors.
Society:
- An inverse relationship exists between socioeconomic status and obesity prevalence: lower income is often associated with higher rates of obesity.
- Variations in ethnicity and sex also impact obesity prevalence (e.g., morbid obesity is more common in women than men, and highest among Black adults compared to White, Asian, and Hispanic adults).
Culture:
- Bias, stigma, and discrimination surrounding weight can create emotional and psychological challenges for individuals. For example, White women are more likely to experience body dissatisfaction and feel overweight compared to Black and Hispanic women.
Environmental Chemicals:
- Endocrine-disrupting chemicals (e.g., diphenhydramine) and steroids like glucocorticoids (e.g., hydrocortisone, prednisone) are known to potentially contribute to weight gain.

Red Flags Findings

Rapid weight gain over days to weeks
Difficulty breathing or coughing at night
Increased thirst or urination
Inability to sleep lying flat
Blurry vision
Recent increases in waist or pant size
Pain or stiffness in joints
Yellowing of skin or whites of eyes (jaundice) or tea-coloured urine
Prolonged or excessive bleeding
Reduction in urination
Nausea, vomiting, generalized itch
Swelling in feet, ankles, or legs

Obesity Comorbidities

Common health conditions associated with obesity:
- Coronary artery disease
- Congestive heart failure
- Stroke
- Emphysema, chronic bronchitis, or obstructive pulmonary disease
- Pulmonary embolism
- Deep vein thrombosis
- Cancer
- Diabetes
- Hypercholesterolemia
- Hypertension
- Depression
- Macular degeneration
- Cataract removal
- Neck, back, or joint pain
- Frequent headaches
- Stress
- Fatigue/lack of energy
- Feeling depressed/anxious
- Chronic insomnia
- Indigestion or heartburn
- Impotence
- Skin problems
- Bladder and yeast infections
- Osteoarthritis
- Gingivitis
- GERD
- Ulcers
- Gallbladder removal
- Pancreatitis
- Kidney disease (+ stones)
- Asthma

Classification of Obesity by BMI, WC, and Associated Disease Risk

BMI (kg/m2) | Obesity Class | Male ≤102cm (40in) | Male >102cm (40in) | Female ≤88cm (35in) | Female >88cm (35in)
------ | -------- | -------- | -------- | -------- | -------- Underweight | < 18.5 | | | | | Normal | 18.5 - 24.9 | | Increased | | Increased | Overweight | 25.0 - 29.9 | Increased | High | Increased | High | Obesity | 30.0 - 34.9 | I | High | Very High | 35.0 - 39.9 | II | Very High | Very High | ≥40 | III | Extremely High | Extremely High | Extremely High | Extremely High
Diseases associated with obesity: type 2 diabetes, hypertension, coronary heart disease

Proportion of Disease Prevalence Attributable to Obesity

Type 2 diabetes: 61%
Uterine cancer: 34%
Gallbladder disease: 30%
Osteoarthritis: 24%
Hypertension: 17%
Coronary heart disease: 17%
Breast cancer: 11%
Colon cancer: 11%

Serious Comorbid Disease Prevalence in Obese Population

Type 2 diabetes: 7-20%
Hypertension: 49-65%
Hyperlipidemia: 34-41%
Coronary heart disease: 10-19%
Sleep apnea: 8-15%
Osteoarthritis: 5-17%
Non-alcoholic fatty liver disease (NAFLD): 60-90%

Physiological Effects of Obesity

Increased cardiac output
Increased metabolic rate
Increased sympathetic tone
Increased thyroid hormone
Hyperinsulinemia
Increased insulin resistance
Increased visceral fat storage
Decreased energy expenditure
Increased sodium retention
Increased portal blood free fatty acids
Increased estrogen
Decreased HDL cholesterol
Increased LDL cholesterol
Increased cholesterol excretion
Increased vasoconstriction
Increased risk of heart failure
Increased risk of diabetes
Increased risk of gallstones
Increased risk of cancer
Increased risk of hypertension
Increased risk of coronary artery disease

Relative Risk (RR) of Obesity and Heart Disease Risk Factor Development

Risk factor | Sex | BMI 25 - 29.9 | BMI ≥ 30
------ | -------- | -------- | -------- Hypertension ( >1 30/80 mmHg) | Male| 1.46 | 2.21 | Hypertension (> 130/80 mmHg) | Female | 1.75 | 2.75 | Hypercholesterolemia ( ↑ total, LDL chol.) | Male | 1.19 | 1.11 | Hypercholesterolemia ( ↑ total, LDL chol.) | Female | 1.35 | 1.16 | Diabetes mellitus ( ↑ FBG, HbA1c) | Male | 1.33 | 2.12 | Diabetes mellitus ( ↑ FBG, HbA1c) | Female | 0.97 | 1.42 |

Relative Risk (RR) of Obesity and Heart Disease

Cardiovascular disease outcome | Sex | BMI 25 - 29.9 | BMI ≥ 30
------ | -------- | -------- | -------- Angina pectoris | Male | 1.47 | 1.81 | Angina pectoris | Female | 1.42 | 1.63 | Myocardial infarction (MI) | Male | 1.26 | 1.17 | Myocardial infarction (MI) | Female | 0.91 | 1.46 | Total coronary artery disease | Male | 1.43 | 1.58 | Total coronary artery disease | Female | 1.22 | 1.54 | Cerebrovascular disease | Male | 1.28 | 1.61 | Cerebrovascular disease | Female | 1.10 | 1.02 | Total heart disease | Male | 1.24 | 1.38 | Total heart disease | Female | 1.13 | 1.38 | Cardiovascular disease death | Male | 1.05 | 0.98 | Cardiovascular disease death | Female | 0.77 | 1.56 |
Adjusted for age, smoking, hypertension, hypercholesterolemia, and diabetes.

Type 2 Diabetes Mellitus (T2DM)

Chronic metabolic disorder characterized by persistent hyperglycemia, caused by ineffective response to insulin (insulin resistance)
Makes up 90% of diabetes cases
Prevalence in Canada: 8.8%
Risk factors: obesity, unhealthy diet (high in ultra-processed foods), physical inactivity, lower socioeconomic status, increased age (over 45 years), family history, and ethnicity (increased risk among Black, South Asian, Indigenous peoples)
Signs and symptoms: increased thirst, increased hunger, increased urination, fatigue, acanthosis nigricans, proneness to infections, delayed wound healing, potential peripheral neuropathy (numbness or tingling in hands/feet), or blurry vision
Diagnosis: Hemoglobin A1c (HbA1c) or fasting blood glucose (FBG)
- FBG > 7.0 mmol/L OR HbA1c > 6.5%
Management: Diet + lifestyle modification (weight loss)
Prognosis: 15% higher mortality, increased risk of atherosclerotic cardiovascular disease

T2DM + Obesity

80% of patients with T2DM are obese
7-20% of obese adults have T2DM

Obstructive Sleep Apnea (OSA)

Common, chronic disorder where patients temporarily stop or decrease breathing repeatedly during sleep
Estimated prevalence: 2-14% of the population
Risk factors: obesity, advanced age (40-70 years), male, supine sleep position, family history of OSA, retrognathia, commercial motor vehicle driver, postmenopausal women not on HRT
Estimated prevalence in obese adults: 45%
Signs and symptoms: gasping during sleep, morning headache, excessive daytime sleepiness, loud snoring
Diagnosis: polysomnography
Potential indicators: high body mass index (BMI), neck circumference > 40 cm (16 inches), chin position, narrow oropharyngeal opening
Management: Referral for continuous positive airway pressure (CPAP) device
Prognosis: Increased morbidity and mortality (estimated lifespan reduction of 20 years)

STOP-Bang Questionnaire

Self-administered, validated questionnaire to screen for obstructive sleep apnea (OSA)
"STOP" stands for: Snoring, Tiredness, Observed apnea, high blood Pressure
"Bang" stands for: Body mass index (BMI), Age, Neck circumference, and Gender
Scoring System:
- Sensitivity: 90.5% for all OSA in BMI ≥ 30, score ≥ 3
- Sensitivity: 95.8% for all OSA in BMI ≥ 35, score ≥ 3
- Sensitivity: 68.8% for severe OSA in BMI ≥ 30, score ≥ 5
- Sensitivity: 50.0% for severe OSA in BMI ≥ 35, score ≥ 5

Non-Alcoholic Fatty Liver Disease (NAFLD)

Broad term covering a spectrum of conditions, characterized by hepatic steatosis on imaging or histology without secondary causes
Risk factors: obesity, diabetes, dyslipidemia, insulin resistance, metabolic syndrome
Prevalence in obese adults: 80-90%
Signs and symptoms: usually asymptomatic, but may present with fatigue, right upper quadrant (RUQ) pain, thirst, bloating, sleep disturbance
Diagnosis: ultrasound, liver biopsy
- Potential indicators: hepatomegaly, mildly elevated or normal ALT/AST, AST:ALT ratio > 1
- Management Algorithm:
  - If BMI ≥ 25 OR ↑ WC, PLUS 2 or more risk factors of cardiovascular disease (CVD) + diabetes -> Assess risk
  - If no, Advise to maintain weight; address other risk factors.
  - If yes, and Hx of BMI ≥ 25, advise patient to maintain weight.
  - If no, address other risk factors.
  - If patient hasn't lost ≥0.5kg/wk after 6 months of lifestyle modification, requires lifelong monitoring.

Postoperative Follow-up for Bariatric Surgery

The following table shows the recommended postoperative visit schedule for various bariatric surgery types:
- LAGB (laparoscopic adjustable gastric banding)
- LSG (laparoscopic sleeve gastrectomy)
- RYGB (laparascopic Roux-en-Y gastric bypass)
- BPD/BPD-DS (laparoscopic biliopancreatic diversion/BPD-duodenal switch)
Follow-up schedule:
- Initial, interval until stable, once stable (months)
  - LAGB: 1, 1-2, 12
  - LSG: 1, 3-6, 12
  - RYGB: 1, 3, 6-12
  - BPD/BPD-DS: 1, 3, 6
Blood work: CBC, chemistry panel with each visit (iron at baseline and prn)
- Lab tests:
  - Lipid evaluation (every 6-12 months)
  - Bone densitometry (every 2 years)
  - 24-hour urinary excretion yearly (initial at 6 months)
  - Vitamin B12 yearly (3-6 months if supplemented)
  - Folic acid, iron, vitamin D, iPTH (RYGB, BPD/BPD-DS)
  - Vitamin A (every 6-12 months) (optional for RYGB, required for BPD/BPD-DS)
  - Copper, zinc, selenium (RYGB, BPD/BPD-DS)
  - Thiamine (all types)
  - Assessment for anti-hypertensives, gout therapy, and gallstone prophylaxis each visit

5As Framework for Obesity Management in Adults

Ask: Ask permission to discuss weight with the patient. Be non-judgmental and explore their readiness for change.
Assess: Assess BMI, waist circumference, and obesity class. Explore root causes of obesity.

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