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225 Cards in this Set
- Front
- Back
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What is the key overall way to convince patients with reluctance to change to make lifestyle changes? |
- Set highly specific behavior-outcome goals - Set short-term behavior targets - Individualize goals and targets to patient's preferences and progress - Build confidence in small steps - Implement more intensive interventions according to a stepped-care model |
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What risk factors can predict onset of type 2 diabetes? |
- Age - Obesity |
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What percentage of adults were obese in 2001? What percentage of adults weren't engaging in any regular physical activity vs those who aren't doing enough physical activity? |
- Obese: 21% - No regular physical activity: 30% - Not enough physical activity: 45% |
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How common was the prevalence of diabetes in the U.S. in 2000? |
4.5% (however estimates that 1/3 of cases are not diagnosed) |
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What was the percentage of overweight children in 1999-2000? |
15.3% |
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How young have they observed obesity-related impaired glucose in children? |
As young as six years |
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How young have they observed outright type 2 diabetes in children? |
As young as eight years |
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In the Nurses' Health Study what were powerful predictors of diabetes onset in middle-aged female nurses? |
BMI - Diet and exercise predicted risk within each category of BMI |
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What was the intervention, specific outcome goals, and short-term behavior goals for the Da Qing Impaired Glucose Tolerance and Diabetes Study? |
- Six-year intervention; nine group sessions in first year, four per year thereafter - Outcome goals: BMI ≤23, increase physical activity by at least 1-2 units / day - Behavior targets: use change diet with individually set goals for calories, and for daily quantities of cereals, vegetables, metas, milk, and oils; use individually chosen physical activities selected from a list of suggested activities |
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What was the intervention, specific outcome goals, and short-term behavior goals for the Finnish Diabetes Prevention study? |
- Three-year intervention; seven individual sessions in first year, four per year after - Outcome goals: BMI <25, 5-10 kg weight loss was common intermediary goal, increase physical activity - Behavior targets: use exchange diet in which daily calories comprise >50% carbs, <10% saturated fat, <20% other fat, <300 mg cholesterol, 15 g/100 kcal fiber, 1 g protein / kg ideal weight; use stepped approach: initial focus on food proportions, if no weight loss then food amounts tracked, if no loss then use very low calorie diet option |
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What was the intervention, specific outcome goals, and short-term behavior goals for the Diabetes Prevention Program? |
- Three-year intervention; minimum of 20 individual sessions in first year, minimum of 6 per year thereafter plus other types of contact - Outcome goals: 7% weight loss, more encouraged if goal is achieved; at least 150 minutes of physical activity per week - Behavior targets: stepped approach, starting with self-monitoring of foods eaten, then fats, then calories (if needed), then options (if needed); phased-in physical activity and lifestyle modifications |
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What were the findings of the largest study, the Diabetes Prevention Program? |
Intensive lifestyle intervention was more effective than metformin in reducing the incidence of type 2 diabetes |
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What was the incidence of diabetes in the Finnish Diabetes Prevention study for the diet/exercise group compared to the control subjects? |
- Diet/exercise: 11% - Control: 23% |
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What were the findings of the Da Qing paired Glucose Tolerance and Diabetes Study? |
Lifestyle changes lowered diabetes incidence in lean and overweight participants |
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What were the results of the 12-year followup of non-randomized groups, the Malmo Preventive Trial? |
Lifestyle change lowered the mortality rate of participants with impaired glucose tolerance almost to the rate of normal control patients |
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What percentage of participants in the Diabetes Prevention Program were at their physical activity goal of at least 150 minutes per week at the follow-up (average 2.8 years)? |
58% |
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What percentage of participants in the Diabetes Prevention Program were at their weight loss goal of at least 7% of initial body weight at the follow-up (average 2.8 years)? |
38% |
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How does the adherence to one task predict the adherence to others? |
Adherence to one task (e.g., diet) is a poor predictor of adherence to others (e.g., glucose monitoring) |
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It is best to assess and work on how many behaviors at a time? Implications? |
One behavior at a time, therefore physicians should limit intervention to one or two major behaviors at each visit |
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What are the criteria for normal on the fasting plasma glucose and oral glucose tolerance test? |
- Fasting plasma glucose: <110 mg/dL - Oral glucose tolerance: <140 mg/dL |
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What are the criteria for impaired glucose regulation (pre-diabetes) on the fasting plasma glucose and oral glucose tolerance test? |
- Fasting plasma glucose: 110-126 mg/dL - Oral glucose tolerance: 140-200 mg/dL |
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What are the criteria for normal on the fasting plasma glucose, oral glucose tolerance test, and casual plasma glucose (any time of day without regard to last meal)? |
- Fasting plasma glucose: ≥126 mg/dL - Oral glucose tolerance: ≥200 mg/dL - Casual plasma glucose: ≥200 mg/dL + symptoms of diabetes (eg, polyuria, polydipsia, unexplained weight loss) |
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What is the oral glucose tolerance test? |
Given equivalent of 75g of anhydrous glucose dissolved in water; test two-hour post-load glucose |
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What are the potential results of the oral glucose tolerance test? |
- Normal: <140 mg/dL - Pre-diabetes: 140-200 mg/dL - Diabetes: ≥200 mg/dL |
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What are the potential results of the fasting plasma glucose? |
- Normal: <110 mg/dL - Pre-diabetes: 110-126 mg/dL - Diabetes: ≥126 mg/dL |
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What are the stages of lifestyle change? |
- Precontemplation - Contemplation - Preparation - Action - Maintenance - Identification |
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What are the behaviors, goals, and tips for the "pre-contemplation" stage? |
- Not considering change - Goal: move toward thinking about change - Tips: get patient talking "have you ever considered this before?", "what would have to happen to get you to consider this?", emphasize patient autonomy: "I'm concerned about your health... of course this is entirely your decision... I can help you when you're ready to change..." |
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What are the behaviors, goals, and tips for the "contemplation" stage? |
- Considering change - Goal: Move toward preparing for change - Tips: "how have your friends or family members made this change?" "would you like a list of local programs?" "I have some new info comparing various approaches to weight loss." |
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What are the behaviors, goals, and tips for the "preparation" stage? |
- Preparing for change (e.g., reading about diets, asking friends about gyms) - Goal: move toward taking action - Tips: praise preparation, discuss options, assist in setting initial goals and behavior targets, and set a start date |
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What are the behaviors, goals, and tips for the "action" stage? |
- Establishing the change - Goal: maintain change - Tips: praise all efforts, limit suggestions of additional changes to one or two, and begin to anticipate obstacles |
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What are the behaviors, goals, and tips for the "maintenance" stage? |
- Struggling to maintain the goals - Goal: maintain change - Tips: praise all efforts, limit suggestions of additional changes to one or two, and begin to anticipate obstacles |
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What are the behaviors, goals, and tips for the "identification" stage? |
- Incorporating the change into routine and view of self (the new pattern is now automatic, there is little temptation to lapse) - Goal: maintain change - Tips: praise all efforts |
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How can you evaluate a patient's convictions for a goal? |
"How important is it for you to ... eat healthier food?"
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How can you evaluate a patient's confidence for a goal? |
"How confident are you in your ability to succeed in eating a healthier diet?" |
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What is the prevalence of depression in persons with diabetes? |
15-20% |
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When patients with diabetes have depression, what is more likely to happen? |
Less adherence to self-care behaviors and decreased glycemic control |
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What should you do for a patient with depression and diabetes? |
Treat with antidepressants or behavior therapy to improve both depression and glycemic control! |
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What family interventions can improve adherence to diabetic regimens and better metabolic control? |
- Involvement of family members in DM management - Appropriate task sharing and assignment - Decreasing family conflict - Improving communication and family-based behavior procedures (e.g., goal setting, behavior contracting) |
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What should you do for diabetic patients who are having difficulties with basic needs (e.g., housing, finances, job, safe environment)? |
Get a case manager to address their immediate needs and ultimately improve likelihood of treatment adherence - these patients will have little motivation to address complex long-term lifestyle issues |
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What are outcome goals and behavior targets that can be helpful for patients to stay motivated? |
To be achieved within 6 months: - Initial weight loss goal of 7-10% of baseline weight - Physical activity goal of 150 min/week - A single waist measurement (measured at maximum horizontal girth) should be used to help tract high-rise visceral fat |
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What does the waist measurement correlate with? |
Keeps track of high-risk visceral fat, which correlates with: - Fasting plasma glucose levels - Hemoglobin A1c levels - Insulin sensitivity - Independent of BMI |
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When is a waist measurement considered "high risk"? |
>40 inches in men >35 inches in women |
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For diabetic patients having difficulties making lifestyle changes, what other team members can get involved in their care? |
- Diabetes educator - Registered dietician - Qualified nurse case manager - Behavior counselor |
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How frequent should diabetes patients making lifestyle changes be seen? |
Frequent visits for at least 6 months, gradually tapering to no less than once every 3 months |
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What techniques should be used at every session when teaching lifestyle modifications? |
- Self-monitoring - Homework follow-up - Provide choices - Empower patients - Identifying and overcoming barriers - Skill development |
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How can patients self-monitor? |
Have them track all foods eaten and all physical activities |
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How should a physician assign homework to patients? |
- Add to progress note - Check at the next visit - Keep track of major countable behaviors (e.g., physical activity, average calories consumed) or goals (e.g., weight, waist circumference) - Look for any positive points and praise al activity and self-monitoring, even partial adherence - At each visit only make 1-2 additional suggestions starting with the simplest step that is most likely to result in change |
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What kinds of choices can physicians offer their patients with diabetes? |
- Should we first focus on physical activity or healthy eating - Later offer option of counting calories or following a meal plan - Types of physical activity |
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What model is best for empowering patients? |
Coaching model - patients are guided in developing skills in self-sufficiency, which builds confidence while enhancing competence
Provide patients with initial tools, encourage their use, and offer tips to move patients toward their goals |
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What is an important question to ask a patient when they are starting something new? |
Ask about any specific barriers they can identify - use at every office visit
Then brainstorm possible solutions |
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When a patient "slips" up, how can you address this? |
Let them know this is not a failure, but rather an opportunity to learn what works and what doesn't work in overcoming particular obstacles |
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What are advanced skills in maintaining lifestyle changes? |
- Controlling cues - Problem solving - Eating out - Cognitive change - Relapse prevention - Avoiding boredom - Coping - Social support |
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What are some behavior targets and actions for "controlling cues"? |
- Learn to recognize and change environmental and social cues for eating and physical activity - Shop from a list, eat in one place in the house, add exercise cues to several rooms in the house, and add physical activity to social life |
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What are some behavior targets and actions for "problem solving"? |
- Use problem-solving approach to obstacles - Describe, brainstorm, choose, plan, try, and see |
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What are some behavior targets and actions for "eating out"? |
- Learn skills for eating at restaurants and the homes of others - Plan ahead, choose carefully, and assertively ask for what you want |
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What are some behavior targets and actions for "cognitive change"? |
- Talk back to common negative thoughts - Recognize "all or nothing" thinking, excuses, "shoulds", competing with others, and self-defeating thoughts; use thought stopping and reality testing to break patterns |
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What are some behavior targets and actions for "relapse prevention"? |
- Anticipate slips and get back on track - Identify previous triggers of slips, plan ahead for likely triggers, challenge thoughts that a slip means failure (i.e., get back on the horse), and problem solve how to deal with triggers |
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What are some behavior targets and actions for "avoiding boredom"? |
- Vary physical activity to keep motivated - Change some aspect of physical workout each month; take exotic cooking classes |
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What are some behavior targets and actions for "coping"? |
- Learn stress management techniques - Prevent stress by saying no, asking for help, setting realistic goals, problem solving, organizing, planning, and prioritizing - Cope with unavoidable stress by identifying stress, taking breaks, and using self-soothing techniques, relaxation, physical activity, and social support |
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What are some behavior targets and actions for "social support"? |
- Enhance support for lifestyle change - Involve significant others in activities, and develop new social supports compatible with lifestyle changes |
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How does the timeline of intervention affect the maintenance of behaviors? |
The longer the intervention lasts, the more likely the behaviors are to be maintained |
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How do you screen for obesity? |
BMI |
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To whom should adults who have a BMI >30 be referred? |
To intensive, multicomponent behavioral interventions |
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For what should children >6 years with obesity be referred? |
For comprehensive, intensive behavioral interventions to promote improvement in weight status |
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How much weight loss can reduce the risk of heart disease and diabetes? |
>5-10% |
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When should pharmacotherapy for weight loss be offered? |
For adults who have not been able to lose weight through diet and exercise alone and who have: - BMI >30 - BMI >27 and comorbidity |
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When should bariatric surgery be offered for adults? |
For adults who have not been able to lose weight through diet and physical activity alone and who have: - BMI >40 - BMI >35 and obesity-related comorbidity |
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Is physical activity without weight loss useless? |
No, exercise mitigates health-damaging effects of obesity, even without weight loss |
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What are the physical consequences of obesity? |
- Cancer - CV disease - Cholestasis - Dyslipidemia - Gallbladder disease - Glucose intolerance and insulin resistance - Hepatic steatosis - Hypertension - Hyperuricemia and gout - Menstrual abnormalities - Orthopedic problems - Reduction of cerebral blood flow - Sleep apnea - Type 2 diabetes |
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What are the psychosocial consequences of obesity? |
- Depression - Discrimination - Low self-esteem - Negative body image - Negative stereotyping - Social marginalization - Stigma - Teasing and bullying |
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What are the leading causes of death in obese adults? |
- Ischemic heart disease - Diabetes - Respiratory diseases - Cancer (ie, liver, kidney, breast, endometrial, prostate, and colon) |
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What are some barriers identified by physicians for why they don't address their patient's weight? |
- Insufficient time during visits for screening and counseling - Lack of available referral services for patients - Perception that patients will not be willing or able to make lifestyle changes - Poor reimbursement for nutrition and weight-management counseling - Reluctance to discuss weight among physicians who are themselves overweight - Uncertainty about whether interventions will have a positive impact |
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What percent of U.S. adults regularly see a family physician or other PCP? |
80% |
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What is the definition of "overweight"? |
BMI 25-29 |
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What is the definition of "obesity"? |
BMI >30 |
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What types of patients are at increased risk for obesity? |
Women with limited education and lower incomes |
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What racial and ethnic groups have the highest rates of obesity? |
- Non-Hispanic blacks (49.5%) - Mexican Americans (40.4%) - All Hispanics (39.1%) - Non-Hispanic whites (34.3%) |
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How common is obesity in children 2-19 years? |
17% |
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What type of children are more likely to be obese? |
Hispanic boys >> non-Hispanic white boys
Non-Hispanic black girls >> non-Hispanic white girls |
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What are some of the leading causes of preventable death among adults? |
Obesity related conditions: - Heart disease - Stroke - Type 2 diabetes - Some types of cancer (endometrial, breast, colon) |
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What amount of medical costs in the U.S. are spent on problems related to excess weight? |
$147 billion |
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What are the medical costs of excess weight? |
- Direct costs: preventive, diagnostic, and treatment services - Indirect costs: lost income from decreased productivity, restricted activity, absenteeism, loss of future income due to premature death |
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Besides BMI, what are other indicators for potential health risks associated with being overweight or obese? |
- Risk factors for diseases associated with obesity, such as high BP and physical inactivity - Waist circumference as a measure of abdominal adiposity |
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What medication classes can promote weight gain? |
- Anti-convulsants - Anti-depressants - Anti-hypertensives - Anti-psychotics - Corticosteroids - Psychotropics - Sulfonylureas |
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What anticonvulsants promote weight gain? |
- Valproic acid - Carbamazepine |
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What antidepressants promote weight gain? |
- Amitryptyline - Imipramine - Phenelzine |
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What anti-hypertensives promote weight gain? |
- Clonidine - Guanabenz - Methyldopa - Prazosin - Terazosin - Propranolol - Nisoldipine |
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What anti-psychotics promote weight gain? |
- Chlorpromazine - Thiothixene - Haloperidol - Olanzapine - Clozapine - Risperidone - Quetiapine |
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What psychotropics promote weight gain? |
Lithium |
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What diabetes medicines promote weight gain? |
Sulfonylureas - Glipizide - Glyburide |
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What are the risks of having a larger waist circumference? |
Fivefold greater risk of: - Mutliple cardiometabolic risk factors
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Where should you measure a patient's waist? |
At the superior border of the iliac crests |
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What percent of adults meet the criteria for metabolic syndrome? |
34% |
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How does age >60 years affect risk for metabolic syndrome compared to younger adults (20-39 years)? |
Men >60 are 4x more likely Women >60 are 6x more likely |
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What historical information should you get from an overweight patient? |
- Review of meds - Thorough medical history - Age of onset of weight gain - Previous weight-loss efforts - Dietary and exercise habits - History of smoking |
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When should BP, lipids, and fasting glucose be tested? |
If BMI >25 or a waist circumference >35 inches (women) or >40 inches (men) |
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What factors can confer a high absolute risk for premature mortality? |
Three or more of the following: - Age >45 (men) or >55 (women) - Cigarette smoker - Family history of premature coronary heart disease, (MI or sudden death at or before age 55 years in father or 65 in mother) - HDL <35 - Impaired fasting glucose (110-125) - Hypertension (systolic BP >140 or diastolic BP >90) - LDL >160 |
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What indicates a family history of premature coronary heart disease? |
MI or sudden death at or before age 55 years in father or age 65 years in mother |
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What disease processes related to obesity are annoying to patients (and may be what brings them in to see a doctor) but do not affect their life expectancy? |
- Osteoarthritis - Gallstones - Stress incontinence - Amenorrhea - Menorrhagia |
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What are the risk factors comprised by "metabolic syndrome"? |
Risk factors for cardiovascular disease: - Abdominal obesity - Atherogenic dyslipidemia - Elevated BP - Elevated plasma glucose levels |
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What are the criteria for metabolic syndrome? |
Any 3 of 5 criteria: - Elevated waist circumference (>40 in men, >35 in women) - Elevated triglycerides (>150 or drug treatment for elevated TG) - Reduced HDL (<40 in men, <50 in women or drug treatment for reduced HDL) - Elevated BP (>130 systolic, >85 diastolic or drug treatment for HTN) - Elevated fasting glucose (or treatment for elevated fasting glucose): >100 |
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What were the groups in the Diabetes Prevention Program (DPP)? |
- Usual care - Metformin use (850 mg BID) - Intensive lifestyle modification (lose >7% body weight and add >150 minutes of exercise/week) |
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What were the outcomes of the Diabetes Prevention Program (DPP) by group? |
- Decreased progression to diabetes by 60% for those with intensive lifestyle modifications - Decreased progression to diabetes by 31% for those taking metformin |
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What are the goals of behavioral therapy for obesity? |
Reduce and manage weight by: - Monitoring and modifying food intake - Increasing physical activity level - Recognizing and controlling cues that trigger over-eating |
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What is the benefit of behavioral interventions for obesity? |
Results in an average of 6% reduction in body weight, compared with little or no weight loss in a usual-care group after one year |
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What are methods of higher intensity behavioral interventions that can lead to greater weight loss? |
- Self-monitoring - Goal setting - Planning to address barriers to maintaining lifestyle changes over time |
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What is the USPSTF stepwise framework for delivering preventive counseling in primary care? |
5 A's: - Assess - Advise - Agree - Assist - Arrange
Useful for patients who are ready to change |
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What is the first A for evaluation and treatment of obesity? |
Assess: - Severity of obesity with calculated BMI, waist circumference, and comorbidities - Food intake and physical activity in context of health risks and appropriate dietary approach - Medications that affect weight or satiety - Readiness to change behavior and stage of change |
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What is the second A for evaluation and treatment of obesity, after assessment? |
Advise: - Diagnosis of overweight, obese, or severe obesity - Caloric deficit needed for weight loss - Various types of diets that lead to weight loss and ease of adherence - Appropriateness, cost, and effectiveness of meal replacements, dietary supplements, over the counter weight aids, medications, surgery - Importance of self-monitoring |
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What is the third A for evaluation and treatment of obesity, after advising? |
Agree: - If patient is not ready, discuss at another visit - If patient is motivated and ready to change, develop treatment plan - If patient chooses diet, physical activity and/or medication, set weight loss goal at 10% of baseline - If patient is a potential candidate for surgery, review options |
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What is the fourth A for evaluation and treatment of obesity, after agree? |
Assist: - Provide a diet plan, physical activity guide, and behavior modification guide - Provide web resources based on patient interest and need - Identify method for self-monitoring (e.g., diary) - Review food and activity diary on follow-up (reassess if initial goal is not met) |
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What is the fifth A for evaluation and treatment of obesity, after assist? |
Arrange: - Follow-up appointments to meet patient needs - Referral to registered dietician and/or behavioral specialist for individual counseling / monitoring on weight-management class - Referral to surgical program - Maintenance counseling to prevent relapse or weight regain |
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What technique should you use for patients who are ambivalent or hesitant about making lifestyle changes? |
Motivational interviewing - help patients discover their motivation to change by exploring and resolving feelings of ambivalence |
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What are the goals of motivational interviewing? |
Physician asks questions that leads patients to identify healthy choices that they want to make |
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What are the components of motivational interviewing? |
- Agenda setting - Exploration - patient's desires, abilities, reasons, needs - Providing information - Listening and summarizing - Generating options and contracting |
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What is an example of "agenda setting" and the rationale for its use during motivational interviewing? |
- Eg, "Would you mind if I talked with you about your weight?" - Rationale: asking permission emphasizes patient autonomy |
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What is an example of "exploring the patient's desires" and the rationale for its use during motivational interviewing? |
- Eg, "Are you interested in being more active?" - Rationale: assesses value of changing |
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What is an example of "exploring the patient's abilities" and the rationale for its use during motivational interviewing? |
- Eg, "Would you be able to walk for 30 minutes each day?" - Rationale: assesses patient self-efficacy |
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What is an example of "exploring the patient's reasons" and the rationale for its use during motivational interviewing? |
- Eg, "You mentioned that you're now more open to adding exercise to your routine. What makes you open to it now?" - Rationale: assesses current sources of motivation |
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What is an example of "exploring the patient's needs" and the rationale for its use during motivational interviewing? |
- Eg, "How important is it that you get more fit?" - Rationale: assesses degree of motivation |
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What is an example of "providing information" and the rationale for its use during motivational interviewing? |
- Eg, "Obesity has been linked to a greater risk of diabetes and heart disease. Losing even a modest amount of weight can lower your risk. There are several options available to you." - Rationale: conveys hope, relates risk behavior to long-term health outcomes, indicates that there are treatment options |
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What is an example of "listening and summarizing" and the rationale for its use during motivational interviewing? |
- Eg, "It sounds like you are interested in seeing a dietician for nutrition advice but are worried about finding the right one." - Rationale:elicits view of personal health risk and acceptable interventions, identifies sources of ambivalence |
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What is an example of "generating option and contracting" and the rationale for its use during motivational interviewing? |
- Eg, "It sounds like you have several good ideas about how to reduce your calorie intake. Which one do you think would work best? I look forward to hearing about it at our next appointment." - Rationale: patient selected plan, which will be re-evaluated at an agreed on time |
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What are self-monitoring tools? |
- Food diaries - Physical activity logs - Weight records |
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What is the purpose of self-monitoring tools? |
Help patients to identify patterns of behavior |
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What are examples of stimulus-control strategies for weight loss? |
- Eating only at the dining table - Not eating while watching TV - Not keeping snack foods at home - Putting out workout clothes at night as a reminder to exercise in the morning |
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What are behavioral tools that increase the likelihood of success for weight loss? |
- Cognitive restructuring - changing negative though patterns such as "all or nothing" thinking that undermine efforts - Problem solving - anticipating challenging situations and preparing strategies to deal with them - Stress management - identifying and reduce stressors when possible and develop strategies for coping with unavoidable causes of stress |
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What is the best diet? |
A diet that limits calories and can be followed consistently over time |
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How many calories should someone reduce to lose 1-2 pounds per week? |
500-1000 cals per day |
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Individuals who lost weight and maintained the weight loss had what habits in common according to the National Weight Control Registry? |
- Being physically active for at least 60-90 minutes per day - Eating a low-fat diet rich in complex carbs - Eating breakfast every day - Weighing themselves frequently (most at least weakly) |
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What is the physical activity recommendation for all adults? |
At least 150 minutes of moderate intensity or 75 minutes of vigorous intensity aerobic activity per week (or an equivalent combination of these)
Aerobic activity should be performed for at least 10 minutes per session and should be spread throughout the week |
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Is physical activity alone sufficient to produce significant weight loss? |
No, except at very high intensity levels |
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Patients who have lost considerable weight need to do what to maintain their weight loss? |
Engage in higher amounts (>300 minutes/week) or more vigorous exercise |
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What are the criteria for prescription weight-loss drugs? |
- BMI >30 - BMI >27 and an obesity-related condition (e.g., HTN, type 2 diabetes, dyslipidemia) |
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Studies of the efficacy of pharmacologic therapy for weight loss have found what conclusions? |
- All drug interventions were effective in reducing weight compared to placebo - Many studies were of short duration - Many studies had high attrition rates - Few trials have involved direct comparisons of individual agents |
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What are the prescription meds for long-term management of obesity? |
- Orlistat (Xenical) - Lorcaserin (Belviq) - Combination Phentermine-Topiramate extended release (Qsymia) |
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What is the mechanism of action of Lorcaserin? Possible adverse effects? |
- Serotonin 2C receptor agonist - decreases appetite, increases feeling of fullness - Adverse effects: headache, dizziness, fatigue, nausea, dry mouth, constipation |
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What is the mechanism of action of Orlistat? Possible adverse effects? |
- Decreases absorption of fat by 30% (inactivates gastric and pancreatic lipase) - Adverse effects: intestinal cramps, gas, diarrhea, oily spotting |
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What is the mechanism of action of Phentermine and Topiramate extended-release? Possible adverse effects? |
- Decreases appetite, increases feeling of fullness - Adverse effects: increased HR, birth defects, tingling of hands / feet, insomnia, dizziness, constipation, dry mouth |
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What is Orlistat approved for? |
Weight loss and weight maintenance in conjunction with a reduced-calorie diet |
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What is the version of orlistat available without prescription in a reduced-strength form? |
Alli |
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How effective is Orlistat? |
Patients receiving Orlistat + behavioral interventions had weight loss of 8% compared to 5% in control group after 12-18 months |
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What are the benefits of Orlistat other than for weight loss? |
Beneficial effects on BP, insulin resistance, and lipid levels |
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When do adverse effects of Orlistat occur? What should be done about them? |
- Occur early in therapy and then subside as patients adjust to limiting dietary fat to no more than 30% - Should take a fat-soluble vitamin to offset potential losses from fecal fat excretion |
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What are the rare unsafe effects of Orlistat? |
Risk of severe liver disease |
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How expensive is Orlistat? |
~$150/month |
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What is Lorcaserin approved for? |
Adjunct to a reduced calorie diet and increased physical activity for chronic weight management |
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How effective is Lorcaserin? |
As effective as Orlistat but slightly less effective than Phentermine-Topiramate |
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What is the average weight loss with Lorcaserin? |
3-3.7%
47% lost at least 5% of their body weight, compared with 23% for placebo |
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When should you assess the response to Lorcaserin? What benchmark are you looking for? |
At 12 weeks - med should be discontinued if patients do not lose 5% of their body weight |
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How expensive is Lorcaserin expected to be? |
~$120/month |
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What is the mechanism of Phentermine? Topiramate? |
- Phentermine = appetite suppressant - Topiramate = anticonvulsant thought to act as an appetite suppressant |
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What are the adverse effects the FDA is concerned about for phentermine-topiramate? |
- Increased HR - Depression / suicidal ideation - Cognitive impairment
Most common: paresthesia, dizziness, dysgeusia (taste distortion), insomnia, constipation, dry mouth |
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How effective is phentermine-topiramate for weight loss? |
Average weight loss is 6.7% (lowest dose) to 8.9% (recommended dose) over placebo
62% of patients taking lowest dose and 70% taking recommended dose lost at least 5% of their body weight compared to 20% receiving placebo |
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What is the most effective weight-loss drug? |
Phentermine-Topiramate (but concern about its use in patients with cardiovascular disease) |
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When should you follow-up with patients put on phentermine-topiramate? What benchmark are you looking for? |
12 weeks - if patient has not lost at least 3% of body weight, it should be discontinued or dosage increased
If dose increasing, re-evaluate after an additional 12 weeks, if 5% weight loss has not been achieved it should be discontinued |
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Which weight loss drug should be discontinued gradually? Why? |
Phentermine-Topiramate - abrupt cessation can cause seizures |
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How expensive is phentermine-topiramate? |
~$180/month |
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Which weight loss drug is schedule IV? Why? |
Phentermine - because of teratogenic risk |
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What drugs are approve for short-term weight-loss adjuncts? |
Sympathomimetics: phentermine (IV), diethylpropion (IV), benzphetamine (III), phendimetrazine (III) |
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What is the effect of sympathomimetic agents? |
Cause early satiety |
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In what patients are sympathomimetic agents contraindicated? |
- Coronary heart disease - HTN - Hyperthyroidism - History of drug abuse |
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What are the types of bariatric surgeries? |
- Restrictive - limit the size of the stomach - e.g., laparoscopic adjustable gastric banding and vertical sleeve gastrectomy - Malabsorptive - restrict size of stomach and bypass part of the small intestine - e.g., Roux-en-Y bypass |
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What are the most effective forms of bariatric surgery? |
- Roux-en-Y gastric bypass - Vertical sleeve gastrectomy |
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What is the typical outcome for diabetic patients who get bariatric surgery? |
Disease remission in the majority of patients |
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What is essential following bariatric surgery? |
Sustained changes in diet and exercise habits |
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How do you determine obesity in children? |
BMI at or above the 95% percentile for age and sex |
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What are the complications of childhood obesity? |
- Elevated cholesterol - Elevated BP - Social-psychologic difficulties - Predisposes to obesity and morbidity in adulthood |
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What are the physical activity guidelines for children? |
At least 60 minutes per day of moderate or vigorous aerobic activities |
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What are examples of moderate intensity activities for children? |
- Skateboarding - Bicycling |
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What are examples of vigorous intensity activities for children? |
- Jumping rope - Running - Sports - soccer, basketball, hockey |
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How much screen time should children get? |
Maximum of 2 hours per day for children age 2 years or older
If younger than 2, media use of any kind should be discouraged |
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How much is "too much to drink"? |
Increased risk for alcohol-related problems: - Men who drink >4 standard drinks/day (or >14 per week) - Women who drink >3 standard drinks/day (or >7 per week) |
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Drinking at lower levels may be problematic depending on what factors? |
- Age - Coexisting conditions - Use of medications - Pregnancy |
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Why screen for heavy drinking? |
- At risk drinking and alcohol problems are common - Heavy drinking often goes undetected - Patients are likely to be more receptive, open, and ready to change than you expect - You're in the prime position to make a difference |
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How commonly do U.S. adults drink at levels that elevate their risk for physical, mental health, and social problems? |
3 in 10 |
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Of heavy drinkers, how often is there alcohol abuse or dependence? |
1 in 4 |
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What are heavy drinkers at increased risk for? |
- Hypertension - Gastrointestinal bleeding - Sleep disorders - Major depression - Hemorrhagic stroke - Cirrhosis of liver - Several cancers |
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How often are patients with alcohol dependence receiving the recommended care, including assessment and referral to treatment? |
10% |
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Brief interventions by physicians in regards to heavy drinking can have what impact? |
Significant, lasting reductions in drinking levels in at-risk drinkers who aren't alcohol dependent
Some drinkers who are dependent will accept referral to addiction treatment programs
Even for those who don't accept a referral, repeated alcohol-focused visits with a health care provider can lead to significant improvement |
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What are the clinical indications for alcohol screening? |
- As part of a routine exam - Before prescribing a med that interacts with alcohol - In the ED or urgent care center - When seeing patients who are pregnant or trying to conceive - When seeing patients who are likely to drink heavily, such as smokers, adolescents, and young adults - When seeing patients who have health problems that might be alcohol induced, such as cardiac arrhythmia, depression or anxiety, dyspepsia, insomnia, liver disease, trauma - When seeing patients who have a chronic illness that isn't responding to treatment as expected, such as chronic pain, depression, diabetes, heart disease, GI disorders, HTN |
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What is a written self-report instrument for screening for alcoholism? |
AUDIT |
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What single question can be used to screen for alcoholism? |
Ask about heavy drinking days |
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What is a good prescreen question for detecting patients who drink too much? |
Do you sometimes drink beer, wine, or other alcoholic beverages? |
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If the patient says yes to "Do you sometimes drink beer, wine, or other alcoholic beverages?" what should you ask next? |
Ask the screening question about heavy drinking days:
How many times in the past year have you had 5 or more drinks in a day (men) or 4 or more drinks in a day (women?
POSITIVE: 1 or more heavy drinking day, or AUDIT score of ≥8 for men or ≥4 for women |
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If a patient has a negative screen for the heavy drinking question, what should you do? |
Advise staying within these limits:
For healthy men up to age 65 - No more than 4 drinks in a day - No more than 14 drinks in a week
For healthy women (and healthy men over 65) - No more than 3 drinks in a day - No more than 7 drinks in a week |
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When should lower limits or abstinence be recommended in a patient who screens negative for the heavy drinking question? |
- Patients who take meds that interact with alcohol - Patients who have a health condition exacerbated by alcohol - Patients who are pregnant (abstinence) |
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When should you rescreen patients for alcohol problems? |
Yearly |
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What should you do if your patient responds positively to the heavy drinking screening question? |
Your patient is an "at-risk" drinker. Determine the weekly average: - "On average, how many days a week do you drink?" - "On a typical drinking day, how many drinks do you have?"
Multiply to get weekly average |
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After determining the weekly alcoholic beverages, what do you need to check? |
Assess for alcohol use disorders - are there maladaptive patterns of alcohol use causing clinically significant impairment or distress? |
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How can you assess for alcohol abuse? |
Determine whether, in the past 12 months, your patient's drinking has repeatedly caused or contributed to: - Risk of bodily harm (drinking and riving, operating machinery, swimming) - Relationship trouble (family or friends) - Role failure (interference with home, work, or school obligations) - Run-ins with the law (arrests or other legal problems)
If yes to one or more --> your patient has alcohol ABUSE |
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How can you assess for alcohol dependence? |
Determine whether, in the past 12 months, your patient has: - Not been able to stick to drinking limits (repeatedly gone over them) - Not been able to cut down or stop (repeated failed attempts) - Shown tolerance (needed to drink a lot more to get the same effect) - Shown signs of withdrawal (tremors, sweating, nausea, insomnia when trying to quit or cut down) - Kept drinking despite problems (recurrent physical or psychological problems) - Spent a lot of time drinking (or anticipating or recovering from drinking) - Spent less time on other matters (activities that had been important or pleasurable)
If yes to 3 or more --> your patient has alcohol DEPENDENCE |
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If your patient has at risk drinking (no abuse or dependence) what should you do for them? |
Advise and assist - State your conclusion and recommendation clearly: "You're drinking more than is medically safe. I strongly recommend you cut down (or quit) and I'm willing to help." - Gauge readiness to change habits: "Are you willing to consider making changes in your drinking?" |
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If your patient has at risk drinking (no abuse or dependence) and is NOT ready to commit to change at this time, what should you do? |
- Don't be discouraged, ambivalence is common; your advice has likely prompted a change in their thinking; with continued reinforcement they may decide to take action - For now, restate your concern about their health - Encourage reflection by asking them to weight what they like about drinking vs their reasons for cutting down. What are the major barriers to change? - Reaffirm your willingness to help when they are ready |
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If your patient has at risk drinking (no abuse or dependence) and IS ready to commit to change at this time, what should you do? |
- Help set a goal to cut down to within maximum limits or abstain for a time - Agree on a plan, including what specific steps they will take, how drinking will be tracked, how they will manage high-risk situations, who might be willing to help (e.g. significant other or non-drinking friends) - Provide educational materials |
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How should you follow up with a patient with at risk drinking (no abuse or dependence) who has committed to changing? |
Identify whether they were able to meet and sustain the drinking goal.
Document alcohol use and review goals at each visit. |
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How should you follow up with a patient with at risk drinking (no abuse or dependence) who has committed to changing but was NOT able to meet/sustain their drinking goal? |
- Acknowledge that change is difficult - Support any positive change and address barriers to reaching the goal - Renegotiate the goal and plan, consider a trial of abstinence - Consider engaging significant others - Reassess the diagnosis if the patient is unable to either cut down or abstain |
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How should you follow up with a patient with at risk drinking (no abuse or dependence) who has committed to changing but was ABLE to meet/sustain their drinking goal? |
- Reinforce and support continued adherence to recommendations - Renegotiate drinking goals as indicated (e.g., if medical condition changes or if an abstaining patient wishes to resume drinking) - Encourage the patient to return if unable to maintain adherence - Rescreen at least annually |
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What should you do for a patient who screens positive for an alcohol use disorder (abuse or dependence)? |
- State your conclusion and recommendation clearly: "I believe that you have an alcohol use disorder. I strongly recommend that you quit drinking and I'm willing to help." Relate to the patient's concerns and medical findings if present. - Negotiate a drinking goal: abstaining is the safest course for alcohol use disorders, milder forms may be successful at cutting down if unwilling to abstain - Consider referring for additional evaluation by an addiction specialist, especially if dependent - Consider recommending a mutual help group - For patients who have dependence, consider the need for medically managed withdrawal (detox) and consider prescribing a med for alcohol dependence for those who endorse abstinence as the goal - Arrange follow-up appointments including med management support if needed |
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What should you do for a patient who screens positive for an alcohol use disorder (abuse or dependence) at follow-up? |
- Document alcohol use and review goals at each visit; if the patient is receiving a medication for alcohol dependence, medication management support should be provided - Determine whether the patient was able to meet and sustain the drinking goal |
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What should you do for a patient who screens positive for an alcohol use disorder (abuse or dependence) at follow-up when they were NOT able to meet and sustain the drinking goal? |
- Acknowledge that change is difficult - Support efforts to cut down or abstain, while making it clear that you recommendation is to abstain - Relate drinking to problems (medical, psychological, and social) as appropriate - Consider referring to an addiction specialist or consulting with one - Consider recommending a mutual help group - Consider engaging significant others - Consider prescribing a medication for alcohol dependent patients who endorse abstinence as a goal - Address coexisting disorders - medical and psychiatric - as needed |
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What should you do for a patient who screens positive for an alcohol use disorder (abuse or dependence) at follow-up when they were ABLE to meet and sustain the drinking goal? |
- Reinforce and support continued adherence to recommendations - Coordinate care with a specialist if the patient has accepted referral - Maintain meds for alcohol dependence at least 3 months and as clinically indicated thereafter - Treat co-existing nicotine dependence for 6-12 months after reaching the drinking goal - Address co-existing disorders - medical and psychiatric - as needed |
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How effective is advice giving for lifestyle change? |
5-10% |
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What are the characteristics of patient centered approaches to encouraging improved lifestyle factors? |
- Patient does most of the talking - "Meeting between experts" with the concept of reciprocity in the consultation |
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What is "motivation"? |
A state of readiness for change, rather than a personality trait; it may fluctuate over time or from one situation to another, and can be influenced in a particular direction |
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What is the main goal of motivational interviewing? |
Help patients to explore and resolve their ambivalence about the behavior change |
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What are the clinical principles upon which motivational interviewing is based? |
- Express empathy - Develop discrepancy - Avoid argumentation - Roll with resistance - Support self-efficacy |
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What is the goal of the practitioner in motivational interviewing? |
To get patient to recognize any discrepancy between their current behavior and their important goals so that they will present the argument for change |
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What is a signal to change strategy? |
Resistance - it is not opposed, but rather acknowledged and explored, with the view to shifting the patient's perceptions |
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What acronym describes the techniques of motivational interviewing for effective brief interventions? |
FRAMES: - Feedback - Responsibility for change lies within the individual - Advice giving (only with patient permission) - Menu of change options - Empathic style - Self-efficacy is enhanced |
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Should advice be given in motivational interviewing? |
Only with the patient's permission and when given it is accompanied by actively encouraging the patient to make their own choices |
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What is the personal dissonance strategy of motivational interviewing? |
Aims to create dissonance between the patients' positive image of themselves as a person on the one hand and a negative image of themselves on the other
Eg, "Give me some words to describe your positive points as a person. Now give me some words that describe you as you have been with your drinking. How do these two fit together?" |
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A major development in motivational interviewing was to link it to what model of change? |
Trans-Theoretical model - which provided a framework for understanding the change process itself, with MI as a means of facilitating this change process |
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How do you assess the "readiness for change"? |
The extent to which the patient has contemplated the need for change, having considered the pros/cons of change |
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Lack of motivation can be perceived as what kind of problem? |
Perceptual problem - in which the patient sees no (or insufficient) need to change, whereas others (e.g., health professionals) do perceive a problem and need for change |
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How do you resolve ambivalence? |
Focus on the patient's wants, expectations, beliefs, fears, and hopes, with emphasis on the inconsistencies between these and the problematic behavior |
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What does the Health Belief Model suggest? |
Health behavior change depends on the simultaneous occurrence of: (1) The belief that one is susceptible to a health threat or the medical or social consequences of the health threat (2) Sufficient health concern to make the issue relevant (3) Belief that a particular health recommendation would be beneficial in reducing the perceived threat at an acceptable cost |
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What is Bandura's self-efficacy theory? |
The degree to which an individual develops the expectancy that they will be able to perform the desired behaviors (i.e., self-efficacy) is an important factor in behavior change |
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When using the "change ruler" what do you need to discuss first? |
(1) The importance to them of considering making a change in this issue, on a scale of 0-10 - Evaluate why they chose this number and not a higher number (determine obstacles) - Evaluate why they didn't choose a lower number (learn about motivations) - What it would take to move this number a couple of points (obstacles / current readiness to change) |
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After determining the importance of the patient making a change with the "change ruler" theory, what should you ask next? |
(2) Their level of confidence in their ability to succeed if they are to change at this time, on a scale of 0-10 - Evaluate why they chose this number and not a higher number (determine obstacles) - Evaluate why they didn't choose a lower number (learn about motivations) - What it would take to move this number a couple of points (obstacles / current readiness to change) |
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How can you assess readiness with the "change ruler"? |
Unless they are at a 7 or more, we have some work to do before trying to get them to take action on this issue |
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If a patient is not ready due to ranking this change low in importance, what can be done using the "change ruler" theory? |
Further discuss their core values and how their present behavior "fits" with these life priorities
Discussing core values is invaluable as people can only succeed in the difficult task of behavior change when they tap into a deep source of power
If still not ready to change we might offer some printed information and be sure they're not depressed |
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If a patient is not ready due to ranking this change low in confidence, what can be done using the "change ruler" theory? |
Enhance confidence by exploring their successes in other areas of life, or sharing some of our other patients' success stories. Our expression of confidence in them helps.I |
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If the patient is <7 after additional discussion, what should you do? |
Leave them with an empowering affirmation such as the one on side 1 of the ruler: "I'm confident that if and when..." |
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If the patient is >7 after additional discussion, what should you do? |
Proceed to discuss how, when, where, and with whom their plans to change this behavior
The more details the greater chance of success |
