Week 02 - Obesity Moodle Version PDF

Obesity CMS200 Learning Outcomes Analyze the definition, classification, and measurement of obesity using body mass index (BMI) and other methods for assessing body fat. Interpret the prevalence and trends of obesity in various countries, and the factors contributing to its increase, such as...

Obesity CMS200 Learning Outcomes Analyze the definition, classification, and measurement of obesity using body mass index (BMI) and other methods for assessing body fat. Interpret the prevalence and trends of obesity in various countries, and the factors contributing to its increase, such as genetic, cultural, societal, and environmental influences. Examine the concept of energy homeostasis and its relation to obesity, including factors that influence energy balance like metabolic rate, appetite, diet, physical activity, and endocrine disorders. Investigate the health consequences of obesity, including its role as a risk factor for chronic diseases, and its impact on mortality rates, healthcare utilization, and health-related quality of life. Learning Outcomes (continued) Evaluate the comorbid conditions associated with obesity, including diabetes, hypertension, hyperlipidemia, heart disease, stroke, and sleep apnea, and how to detect them. Diagnose patients with obesity, including medical evaluation, referral to specialists, and identification of primary versus secondary weight gain, and communicate a prognosis. Appraise the limitations and caveats in diagnosing obesity, as well as the utility of investigations and laboratory studies in obesity management. Analyze the risks and considerations related to obesity in pregnancy, including gestational diabetes, preeclampsia, maternal complications, birth outcomes, gestational weight gain targets, and breastfeeding rates. Obesity - a multifactorial, chronic condition characterized by excessive or abnormal accumulation of adipose tissue in the body that presents a risk to health - based on body mass index (BMI), but other anthropometric tools include: - Waist circumference measurement - Waist-to-Hip circumference measurement - Skinfold thickness measurement - Dual-energy x-ray absorptiometry (DXA) - Bioelectrical impedance analysis (BIA) - Air displacement plethysmography (ADP) Body Mass Index (BMI) BMI is calculated as weight (kg) divided by height (m) squared. - online calculators available (diabetes.ca) Obesity ≥ 30 kg/m2 - Class I 30 - 34.9 - Class II 35 - 39.9 - Class III 40+ BMI - obesity is commonly assessed using BMI, a simple and quick anthropometric tool that has a low cost - associated with cardiometabolic risk as well as breathing problems, certain cancers and many other health concerns Finding Sensitivity LR + LR - Obesity (BMI ≥ 30 kg/m2) in women 51.4 11.17 0.51 Obesity (BMI ≥ 30 kg/m2) in men 49.6 18.37 0.52 (SciRep, 2020) limitations of BMI - correlates with excess adipose tissue but does not reflect body composition - does not differentiate between fat mass and fat-free mass - does not account for body fat distribution - limited applicability to certain populations including: young adults, athletes, older adults (over 65 years), pregnant females, and certain racial/ethnic groups (Asian, Black and Canadian First Nations, including Inuit) - e.g. Japan uses > 25 kg/m2 as the cut-off for obesity waist circumference - index of central adiposity (abdominal obesity) Male > 40 in. > 102 cm Female > 35 in. > 88 cm waist circumference - waist circumference is measured at the approximate midpoint between the lowest rib and the top of the iliac crest - associated with increased cardiometabolic risk Finding Sensitivity LR + LR - Obesity in women (> 88 cm) 62.4 5.24 0.43 Obesity in men (> 102 cm) 57.0 10.96 0.45 (SciRep, 2020) waist-to-hip ratio (WHR) - waist measurement (same as waist circumference) divided by hip measurement taken around the widest portion of the buttocks - an index to assess of body fat distribution waist Male > 1.0 Female > 0.85 hip waist-to-hip ratio (WHR) - an index to assess of body fat distribution - associated with increased cardiometabolic disease and mortality Finding Sensitivity LR + LR - Obesity in women (> 0.85) 34 - 92 NS NS Obesity in men (> 1.0) 46 - 89 NS NS NS = not significant, limited data + significant heterogenicity (SciRep, 2020) other anthropometric measures Tool Strengths Limitations Dual Energy - expensive X-ray - radiation (cannot be used in - precise Absorptiometry pregnancy) (DXA) - limited use BMI ≥ 35 Bioelectric - convenient, portable - accuracy reduced by poor Impedance - relatively inexpensive hydration status (BIA) - accurate for lean body - under-estimates fat mass in mass (even in elderly) overweight and obese people Skinfold - convenient, portable - hard to calibrate Thickness - inexpensive - not as accurate or reproducible as other methods other anthropometric measures Finding Sensitivity LR + LR - Obesity, BF% or BMI (dual energy x- gold standard for body fat assessment, ray absorptiometry, DXA) used to establish accuracy of BMI Obesity, BMI ≥ 30 (bioelectric 90 90+ 0.1 impedance, BIA), HF-BIA, 2023 Obesity, BF% ≥35 for women and ≥25 57 8.14 0.46 for men (skinfold thickness), 2014 physical examination should assess: - BMI (height + weight) - degree and distribution of body fat (e.g. waist circumference) - overall nutritional status - blood pressure - other relevant physical exams to assess secondary causes of weight gain laboratory - all patients should be screened for comorbid conditions, including: fasting glucose, hemoglobin A1c (HbA1c), lipid panel, and comprehensive metabolic profile (i.e. electrolytes, kidney function, liver function, calcium, glucose)  1 in 3 Canadians data from: Statistics Canada (2022) and health-infobase.canada.ca (2018) North American Obesity Rates, 2011 (macleans.ca) Obesity Rates Around the World, 2016 (source: ourworldindata.org) Considerations in the Development of Obesity medical history patient intake should determine: - the age at onset of weight gain - recent weight changes (watch for rapid weight gain) - family history of obesity - occupational history - eating and exercise behavior - previous weight loss experience - psychosocial factors, including assessment for mood and eating disorders knowing this information will help differentiate between primary and secondary weight gain primary weight gain - the accumulation of adipose tissue that results from an imbalance between caloric intake and energy expenditure. - most common cause of weight gain, Female > Male - weight gain is highest between ages 24-34 years - adults after 55 years tend to lose weight ↑ increased caloric intake appetite ↑ decreased physical activity level basal metabolic rate (BMR) thermic effect of food environmental factors that contribute to weight gain - Increased Caloric Intake - increased consumption of refined grains, sugar and fats (i.e. processed and fast foods) associated with obesity - Eating Patterns - binge and night eating disorders are secondary causes associated with obesity - Alcohol Consumption - intake of “liquid calories”, heavy alcohol consumption is directly associated with weight gain and obesity - Insufficient Sleep - associated with increased appetite and caloric intake - Smoking Cessation - associated with increased caloric intake and decreased energy expenditure environmental factors that contribute to weight gain - Sedentary Lifestyle - e.g. prolonged TV watching is associated with increased risk of obesity (partly due to reduced energy expenditure) and increases risk of chronic disease and overall mortality - Physical Disability - mobility issues changes body composition and reduces energy expenditure (including limitations to physical activity), leading to increased prevalence of obesity environmental factors that contribute to weight gain - Obesogenic environment - abundant food supplies, eating for pleasure and entertainment, urban sprawl reduces walkability - Society - inverse relationship between socioeconomic status and obesity prevalence - ethnicity, sex and their interplay (e.g. morbid obesity more prevalent in women than men, most prevalent among Black adults followed by White, Asian and Hispanic, respectively) - Culture - bias, stigma and discrimination have emotional and psychological consequences (e.g. White women are more likely to experience body dissatisfaction and feel overweight than Black and Hispanic women) - Environmental chemicals - endocrine-disrupting chemicals (e.g. phthalates) brain-gut axis - the communication between the gastrointestinal system, adipose tissue and the brain that controls food consumption - Majority of patients with obesity were found to have abnormalities in: - satiety (21%) - obesity is associated with decreased satiation (a difference of 50 calories per 5 kg/m2 of BMI), decreased peptide YY - gastric motor function: increased gastric capacity/volume (14%), accelerated gastric emptying (11%) - psychological factors (13%) - increased depression and anxiety secondary weight gain - the accumulation of adipose tissue that results from: - genetic syndromes - other medical conditions (e.g. neuro-endocrine disorders), or - medication side effects - secondary causes can co-exist with primary obesity genetic contribution to (secondary) weight gain - up to 90% of the inter-individual variation in fat mass has a genetic etiology - genetics influence: total body fat, fat-free mass, body fat distribution, basal metabolic rate, physical activity, macronutrient intake and eating behavior - rarely associated with a single genetic mutation - genes affect control of the leptin/melanocortin pathway that regulates food intake (e.g. Ob (Lep) gene) - multiple genes (polygenic effects) contribute to most cases of obesity (300+ genes associated with obesity) - Prader-Willi syndrome, Laurence-Moon syndrome, Cohen syndrome, and Biemond syndrome - rapid increase in obesity implicates environmental and behavioural factors endocrine disorders associated with weight gain - Cushing’s Syndrome (aka. hypercortisolism) - prolonged exposure to high circulating levels of cortisol - altered metabolism causes fat redistribution (visceral adiposity) and insulin resistance (20-47% have comorbid diabetes mellitus) - Hyperinsulinemia - elevated serum insulin levels - often due to insulin-resistance, may precede Type 2 diabetes by 10-15yrs - Hypothyroidism - low serum thyroid hormone - rerduced BMR and thermogenesis, 25, fHx, PHx (CVD, PCOS, hypertension, low HDL, HbA1c >5.7) diagnosis: 2-step screening + diagnostic approach typically done 24-28 weeks - 50g 1hr oral glucose challenge test - plasma glucose (PG) ≥ 11.1 mmol/L at 1hr - if 7.8-11 mmol/L, complete 2hr 75g oral glucose challenge test - GDM if fasting PG ≥ 5.3, 1h PG ≥ 10.6, 2h PG ≥ 9.0 mmol/L management: may be managed with diet (A1GDM) or medication (A2GDM) prognosis: increased risk of stillbirth, pre-eclampsia, shoulder dystocia, c-section, large for gestational age infants - 35-60% risk of T2DM in 10-20 yrs AAFP, 2015 pre-eclampsia - new-onset of hypertension with systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg after 20 weeks of gestation with proteinuria and/or end-organ dysfunction (renal dysfunction, liver dysfunction, central nervous system disturbances, pulmonary edema, thrombocytopenia) autoimmune disease, chronic hypertension, diabetes (type 1 or 2), Hx of pre- eclampsia, muti-fetal gestation, renal disease; age > 35yrs, Black race or low socioeconomic status, fHx pre-eclampsia (mother, sister), BMI >30, nulliparity new onset headache (+/- visual disturbance), RUQ or epigastric pain with associated N/V, dyspnea, increase in swelling diagnosis: BP ≥ 140/90 mmHg, plus proteinuria or one of the following: - thrombocytopenia (low platelets), ↑ AST +/- ALT, ↑ creatinine management: co-manage with OBGYN (BP control and seizure prevention) prognosis: good with early detection and delivery at 37 weeks (or 34 weeks if severe)  Hypertensive Disorders of Pregnancy (AAFP, 2004) Pregnant woman with BP ≥ 140/90 mmHg before 20 weeks after 20 weeks of of gestation gestation new or increased no or stable proteinuria, increasing BP proteinuria no proteinuria proteinuria or HELLP syndrome Pre-eclampsia super- Chronic Gestational imposed on chronic Pre-eclampsia hypertension hypertension hypertension HELLP: hemolysis, elevated liver enzymes, low platelet count maternal complications in obese population - increased risk of labour induction (OR 1.7) with increased risk of failed induction - increased risk of shoulder dystocia (secondary to fetal macrosomia and excess pelvic adiposity) - higher incidence of cesarean deliveries (6X more often in obese women) - 44% increased risk of postpartum hemorrhage in women with BMI > 30 - increased postpartum weight retention impact on health resources - technical challenges in assessment - challenges with instrumentation of labour - need for specialized equipment, additional team members and training - complications with anesthesia - prolonged hospital stays (+0.5 days or greater)  10.3945/ajcn.2009.28950 Results: The women who gained excess weight during pregnancy had increased odds of being overweight [odds ratio (OR): 2.15; 95% CI: 1.64, 2.82] or obese (OR: 4.49; 95% CI; 3.42, 5.89) 21 y after the index pregnancy. These associations were independent of other potential factors. Conclusion: Weight gain during pregnancy independently predicts the long-term weight gain and obesity of women birth outcomes for mothers with obesity - risk of pregnancy loss is 25-37% higher in obese women - risk of stillbirth is 1.7X (class I obesity), 2X (class II), 2.5X (class III) - increased risk of congenital abnormalities (e.g. 7% increased risk of neural tube defects) - increased risk of macrosomia offspring outcomes - children of obese mothers are at an increased risk of developing obesity and metabolic disorders in childhood + adulthood - evidence also suggests increased risk of neuro-developmental concerns (e.g. Autism Spectrum Disorder), as well as asthma breastfeeding - increased risk of failure to initiate (13% less likely) and decreased duration recommended weight gain in pregnancy ​Pre-pregnancy ​Recommended total weight ​Average weekly weight gain in BMI gain for pregnancy 2nd and 3rd trimesters < 18.5 12.5 - 18kg (28 - 40lbs) 0.5kg (1.0lb) each week 18.5 - 24.9 11.5 - 16kg (25 - 35lbs) 0.4kg (1.0lb) each week 25.0 - 29.9 7 - 11.5kg (15 - 25lbs) 0.3kg (0.6lb) each week ≥ 30 5 - 9kg (11 - 20lbs) 0.2kg (0.5lb) each week Health Canada, 2022 menopause + weight gain - a non-pathologic estrogen-deficient condition involving the permanent cessation of menses for at least 12 months - altered body composition: associated with modest increase in body weight and total body fat (visceral and central abdominal fat most significantly increased) - reduced energy expenditure: associated with significant reduction in spontaneous activity and due to reduced lean body mass - mood: increased risk of depression, which is associated with increased food intake and decreased physical activity - menopausal women are 3X more likely to develop obesity and metabolic syndrome abnormalities than premenopausal women - 20% of patients gain ≥ 9.9 lb during a 3-year period medications associated with weight gain 10.2147/DMSO.SS171365 Drug class Medications that cause clinically significant weight gain Anti-diabetics Insulin, Meglitinides, Sulfonylureas, Thiazolidinedones Anti-hypertensives Alpha-adrenergic blockers, Beta-adrenergic blockers (atenolol, metoprolol, nadolol, propranolol) Anti-depressants Lithium, MAO inhibitors, Mirtazapine, SNRIs (duloxetine, venlafaxine), SSRIs (citalopram, paroxetine), TCAs (amitriptyline, desipramine, dosepin, imipramine, nortiptyline) Anti-psychotics Clozapine, Haloperidol, Olanzapine, Quetiapine, Risperidone Anti-epileptics Carbamazepine, Gabapentin, Pregabalin, Valproic acid Contraceptives Medroxyprogesterone acetate Anti-histamines First-generation antihistamines (e.g. diphenhydramine) Steroids Glucocorticoids (e.g. hydrocortisone, prednisone) 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 increase in waist or pant-size Pain or stiffness in joints Yellowing of skin or whites of eyes Chest tightness or pressure brought (jaundice) OR tea-coloured urine on by exertion or emotional stress Prolonged or excessive bleeding Snoring or stop breathing at night Reduction in urination Difficulty staying awake during day Nausea, vomiting, generalized itch Swelling in feet, ankles or legs diagnostic algorithm: weight gain Secondary weight gain Referral or co- management Current Medical Diagnosis & Treatment, 2023 (Ch14 library access) Obesity Comorbidities health conditions associated with obesity (Am J Prev Med, 2004) Coronary artery disease Depression Knee + hip replacement Congestive heart failure Macular degeneration Neck, back or joint pain Stroke Cataract removal Frequent headaches Emphysema, chronic Glaucoma Stress bronchitis, or obstructive Asthma Fatigue/lack of energy pulmonary disease Gingivitis Feeling depressed/ Pulmonary embolism anxious GERD Deep vein thrombosis Chronic insomnia Ulcers Cancer Indigestion or heartburn Gallbladder removal Diabetes Impotence Pancreatitis Hypercholesterolemia Kidney disease (+ stones) Skin problems Hypertension Bladder + yeast infections Osteoarthritis Classification of Obesity by BMI, Disease risk* (relative to normal weight WC and associated disease risk and waist circumference) BMI Obesity Male ≤102cm (40in) Male >102cm (40in) (kg/m2) class Female ≤88cm(35in) Female >88cm(35in) Underweight < 18.5 Normal 18.5 - 24.9 Increased Overweight 25.0 - 29.9 Increased High Obesity 30.0 - 34.9 I High Very High 35.0 - 39.9 II Very High Very High Extreme ≥ 40 III Extremely High (SciRep, Extremely 2020) High obesity *diseases: type 2 diabetes, hypertension, coronary heart disease (WHO, 1997) proportion of disease prevalence attributable to obesity Disease Prevalence (%) Type 2 diabetes 61 Uterine cancer 34 Gallbladder disease 30 Osteoarthritis 24 Hypertension 17 Coronary heart disease 17 Breast cancer 11 Colon cancer 11 (Obesity Research, 2002) serious comorbid disease prevalence in obese population Disease Prevalence (%) 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 60 - 90 The Patient History: An Evidence-Based Approach to Differential Diagnosis, Ch.14 library access  ↑ Cardiac output Heart Failure ↑ Metabolic rate Hyperinsulinemia ↑ Sympathetic tone ↑ Insulin resistance Diabetes ↑ Thyroid hormone ↑ Portal blood free fatty acids ↑ Caloric Intake ↑ Visceral fat storage ↓ Energy expenditure ↑ sodium retention OBESITY Kidneys ↑ Estrogen ↑ cardiac output Heart ↓ HDL + ↑ LDL ↑ Cholesterol excretion ↑ vasoconstriction Blood vessels Gallstones Cancer Coronary Artery Current Medical Diagnosis & Hypertension Disease Treatment, 2023 (library access) relative risk (RR): obesity + heart disease risk factor development Age-adjusted RR Age-adjusted RR risk factor sex BMI 25 - 29.9 BMI ≥ 30 hypertension male 1.46 2.21 (> 130/80 mmHg) female 1.75 2.75 hypercholesterolemia male 1.19 1.11 (↑ total, LDL chol.) female 1.35 1.16 diabetes mellitus male 1.33 2.12 (↑ FBG, HbA1c) female 0.97 1.42 (JAMA, 2002) relative risk (RR): obesity + heart disease Adjusted* RR Adjusted* RR cardiovascular disease outcome sex BMI 25 - 29.9 BMI ≥ 30 male 1.47 1.81 Angina pectoris female 1.42 1.63 male 1.26 1.17 Myocardial Infarction (MI) female 0.91 1.46 male 1.43 1.58 Total Coronary Artery Disease female 1.22 1.54 male 1.28 1.61 Cerebrovascular Disease female 1.10 1.02 relative risk (RR): obesity + heart disease (continued) Adjusted* RR Adjusted* RR cardiovascular disease outcome sex BMI 25 - 29.9 BMI ≥ 30 male 1.24 1.38 Total Heart Disease female 1.13 1.38 male 1.05 0.98 Cardiovascular Disease Death female 0.77 1.56 *Adjusted for age, smoking, hypertension, hypercholesterolemia and diabetes. JAMA, 2002 type 2 diabetes mellitus (T2DM) - a chronic metabolic disorder characterized by persistent hyperglycemia due to ineffective response to insulin (i.e. insulin resistance) 90% of diabetes cases, 8.8% of Canadians diagnosed with diabetes obesity, unhealthy diet (e.g. high in ultra-processed foods), physical inactivity, lower socioeconomic status, increased age (>45 yrs), family history + ethnicity (e.g. increased risk among Black, South Asian, Indigenous peoples) increased thirst, increased hunger, increased urination, fatigue acanthosis nigricans, prone to infections, delayed wound healing; may also have peripheral neuropathy (numbness or tingling in hands/feet) or blurred 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 atherosclerotic cardiovascular disease T2DM + obesity - 80% of patients with T2DM are obese - 7-20% of obese adults have T2DM free fatty acids osmosis.org obstructive sleep apnea (OSA) - a common, chronic disorder that causes patients to temporarily stop or decrease their breathing repeatedly during sleep estimated 2-14% of population obesity, advanced age (40-70yrs), male, supine sleep position, fHx of OSA, retrognathia, commercial motor vehicle driver, postmenopausal women not on HRT - estimated prevalence 45% in obese adults gasping during sleep, morning headache, excessive daytime sleepiness, loud snoring diagnosis: polysomnography - BMI, neck circumference > 40 cm (16 inches), chin position, narrow oropharyngeal opening management: referral to access Continuous Positive Air Pressure (CPAP) device prognosis: increased morbidity and mortality (estimated lifespan –20yrs) AAFP, 2016 STOP-Bang questionnaire - The loud Snoring, Tiredness, Observed apnea, high blood Pressure (STOP)-Body mass index (BMI), Age, Neck circumference, and Gender (Bang) questionnaire is a self-administered, validated questionnaire to screen for obstructive sleep apnea (OSA) Finding Sensitivity LR + LR - all OSA in BMI≥30, score ≥ 3 90.5% 1.26 0.34 all OSA in BMI≥35, score ≥ 3 95.8 1.05 0.46 severe OSA in BMI≥30, score ≥ 5 68.8% 2.2 0.45 severe OSA in BMI≥35, score ≥ 5 50.0% 2.69 0.61 (ObesSurg, 2013) AAFP, 2016 adiposity around neck weighs down airways when lying osmosis.org non-alcoholic fatty liver disease (NAFLD) - a broad term used to cover a spectrum of conditions characterized by hepatic steatosis on imaging or histology and the absence of secondary causes obesity, diabetes, dyslipidemia, insulin resistance, metabolic syndrome - prevalence of NAFLD is 80-90% in obese adults asymptomatic; fatigue, RUQ pain, thirst, bloating, sleep disturbance diagnosis: ultrasound, liver biopsy - hepatomegaly, mildly elevated or normal ALT / AST, AST:ALT 88cm F, Assess risk BMI ≥ 25 or height + WC; > 102cm M factors of CVD + ↑WC, PLUS calculate BMI diabetes* 2 or more NO risk factors YES Advise to Hx of BMI ≥ 25 maintain weight; NO NO address other risk factors Brief reinforcement / education Does patient about weight management want to lose NO weight? periodic weight (Obesity Research, 2002) check risk assess. BMI ≥ 25 or 5-10% of body Clinician + Patient devise goals and cont. ↑WC, PLUS YES weight loss treatment strategy for weight loss or from 2 or more and risk factor control 0.5-1.0kg/wk previous risk factors slide over 6 months NO Assess Progress or NO Does patient YES reasons for goal want to lose failure to achieved? NO weight? lose weight YES Maintenance counseling: periodic weight Dietary therapy check Behavioural therapy Physical activity (Obesity Research, 2002)  Progress or goal achieved? eCPS (library access) NO Assess reasons for failure to lose weight (and reinforce goals) BMI ≥ 30 or BMI ≥ 40 or BMI ≥ 27 and BMI ≥ 30 or BMI ≥ 35 and ≥ 2 risk factors BMI 25-29.9 and ≥ 2 risk factors ≥ 2 risk factors Lifestyle modification + Weight loss surgery: adjunctive Lifestyle modification: consider only if other pharmacotherapy: diet + physical activity attempts at weight loss consider if the patient has + behavioural therapy have failed. Requires not lost ≥0.5kg/wk after 6mo lifelong monitoring. of lifestyle modification postoperative follow-up for bariatric surgery eCPS (library access) LAGB LSG RYGB BPD/BPD-DS Follow-up (band) (sleeve) (bypass) (duodenal switch) Visit: initial, interval until stable, 1, 1-2, 1, 3-6, 1, 3, 6- 1, 3, once stable (months) 12 12 12 6 CBC, chemistry panel with each Y Y Y Y visit (iron at baseline and prn) Lipid evaluation every 6-12 mo Y Y Y Y Bone densitometry every 2 yr Y Y Y Y 24hr urinary excretion yearly Y Y Y Y (initial at 6mo) LAGB = laparoscopic adjustable gastric banding, LSG = laparoscopic sleeve gastrectomy, BPD/BPD-D = laparoscopic biliopancreatic diversion/BPD-duodenal switch, RYGB = laparascopic Roux-en-Y gastric bypass postoperative follow-up for bariatric surgery eCPS (library access) LAGB LSG RYGB BPD/BPD-DS Follow-up (band) (sleeve) (bypass) (duodenal switch) Vitamin B12 yearly (3-6mo if Y Y Y Y supplemented) Folic acid, iron, vitamin D, iPTH N N Y Y Vitamin A every 6-12 months N N optional Y Copper, zinc, selenium N N Y Y Thiamine Y Y Y Y Assess need for anti- hypertensives, gout therapy, and Y Y Y Y gallstone prophylaxis each visit 5As framework for obesity management in adults (CMAJ, 2020) ASK Ask permission to discuss weight. Be non-judgmental and explore readiness for change. ASSESS Assess BMI, waist circumference and obesity class. Explore root causes of obesity. ADVISE Advise on health risks of obesity, benefits of modest weight loss, need for long-term strategy, treatment options. AGREE Agree on realistic weight loss expectations and targets, personalized specifics of treatment plan. ASSIST Assist in identifying and addressing drivers and barriers. Provide education and resources. Refer to appropriate providers. Arrange for regular, timely follow-up. 5A Toolkit - obesitycanada.ca  (CMAJ, 2021) Medical Mental Functional Edmonton Obesity - ranks mortality risk in overweight individuals based on Staging System obesity-related comorbidities and functional status. percent of patients in obesity class by EOSS stage (CMAJ, 2021) Edmonton Obesity Staging System (CMAJ, 2011) Edmonton Obesity Staging System (CMAJ, 2021) - increasing stages are associated with increased risk Stage 0 1 2 3 4 Post-operative mild-4.1% 3.4% 5.6% 5.9% 5.0% complication rate severe-0% 0% 0.33% 1.91% 1.75% Mortality rate 0% 0% 0.13% 0.71% 0.45% (30-day) C-section odds 1.3 0.97 1.7 21.7 - ratio other care considerations related to Obesity - obesity is a leading cause of chronic health conditions - estimated 1 in 10 premature deaths attributable to obesity - obesity is associated with physical and mental health conditions (sleep disorders, anxiety, depression, eating disorders, and serious psychiatric disorders) - social stigma and inequities in access to employment and education contribute to healthcare challenges - healthcare utilization direct annual cost in Canada was estimated to be $3.9 billion in 2006 (includes physician visits, hospitalization and medication costs) - indirect costs were $3.2 billion (includes long-term disability, morbidity due to short-term disability) patient education - obesity is associated with increased mortality, mostly due to comorbidity: - type 2 diabetes, heart disease, depression, liver disease, sleep apnea, osteoarthritis, certain cancers, etc. - weight loss of 5-10% is sufficient in many patients to achieve clinically relevant improvements in many risk factors (hypertension, dyslipidemia, dysglycemia) in a “dose-dependent” manner - weight loss is challenging, emphasize weight gain prevention when possible  key resources 1. Dalect D, Schauer D. Obesity in Adults. Am Fam Physician. 2010;82(8):974- 975 https://www.aafp.org/pubs/afp/issues/2010/1015/p974.html 2. Saunders KH, Igel LI. Obesity. In: Papadakis MA, McPhee SJ, Rabow MW, McQuaid KR. eds. Current Medical Diagnosis & Treatment 2023. McGraw Hill; 2023. Accessed April 29, 2023. (library access) 3. Loo TS. Chapter 14. Weight Gain. In: Henderson MC, Tierney LM, Jr., Smetana GW. eds. The Patient History: An Evidence-Based Approach to Differential Diagnosis. McGraw Hill; 2012. Accessed April 29, 2023. (library access)  key resources 4. Sharma AM. Obesity. In: Therapeutics [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2016 [updated Apr 2021; cited 2023 Jul 23]. Available from: http://www.myrxtx.ca. Also available in paper copy from the publisher. (library access) 5. Panuganti KK, Nguyen M, Kshirsagar RK. Obesity. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:https://www.ncbi.nlm.nih.gov/books/NBK459357/