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135 Cards in this Set

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Case 1:
- 45 yo Caucasian male comes to establish care
- PMH: asthma, seasonal allergies, osteoarthritis, depression
- Meds: for depression, daily OTC pain killers for knee pain
- FHx: obesity and T2DM in father and older brother; thyroid condition in mother
- SHx: non-smoker, drinks 6-pack of beer/weekend, no drug use; handy man
- ROS: gradual weight gain for few years, bilateral knee pain on prolonged walking
- Exam: central obesity w/ facial rounding, BP 148/92, skin tags on neck
- Labs: glucose 160, cholesterol 235, LDL 115, HDL 28, TG 366, HbA1c 7.8%, normal TSH

What would you diagnose him with?
- Diabetes
- High blood pressure
- Obesity
Which one of the following diseases have been linked to obesity?
a) Non-alcoholic steatohepatitis (NASH)
b) Polycystic ovarian syndrome
c) Type 2 diabetes mellitus
d) Breast cancer
e) All of the above
All of the above
What causes obesity?
Long-term positive energy balance
- More energy intake than energy expenditure
How common is obesity?
Worldwide:
- 1.4 billion adults (>20) affected
- 500 million of them are obese
What is an underweight BMI?
<18.5
What is a normal BMI?
18.5 - 24.9
What is an overweight BMI?
25.0 - 29.9
What is an obese (class 1) BMI?
30.0 - 34.9
What is an obese (class 2) BMI?
35.0 - 39.9
What is an obese (class 3) BMI?
≥ 40.0
How do you assess BMI?
Body weight (in kg) / height (in m) squared
What are the risks associated with obesity?
- ↑ Mortality
- ↑ Disease risk: T2DM, cholelithiasis, HTN, coronary heart disease
- Psychosocial impact (depression, lower salary, lower educational achievement, relationship difficulties, daily activities impaired, discrimination)
- ↑ Mortality
- ↑ Disease risk: T2DM, cholelithiasis, HTN, coronary heart disease
- Psychosocial impact (depression, lower salary, lower educational achievement, relationship difficulties, daily activities impaired, discrimination)
How much does morbid obesity decrease the life span?
5-12 years
What are the medical complications of obesity?
What is the psychosocial impact of obesity?
- Depression
- Lower salaries
- Lower educational achievement
- Relationship difficulties
- Daily activities impaired
- Discrimination
Which type of distribution of fat is worse (apple or pear)?
Apple (central obesity) is worse than pear (more weight below waist)
Apple (central obesity) is worse than pear (more weight below waist)
Why is a BMI an imperfect measure?
- Cannot distinguish between fat mass and lean body mass
- Questionable validity in older adults: substantial loss in lean body mass
- Low BMI could be due to underlying illness (U-shaped relationship between BMI and mortality)
- Confounding by smoking
- Radial and gender differences
What waist circumference in men and women is considered as high risk for disease relative to normal weight and waist circumference?
- Men: >102 cm (40 inches)
- Women: >88 cm (34 inches)
How do you determine the body fat percentage? What is it measuring?
Total mass of fat / total body mass

- Includes essential body fat and storage body fat
- Percentage of essential fat for women is greater than for men, due to demands of childbearing and other hormonal functions
What percent of a body weight is essential fat in men and women?
- Men: 2-5%
- Women: 10-13%
Mr. DK tells you that he does not eat much and surely something else is wrong. What did you consider as potential causes of his obesity before concluding that he does not need further work up?
a) You called his pharmacy to obtain complete list of his medications.
b) Reviewed his alcohol intake.
c) Paid attention to physical signs that could lead to a diagnosis of hormonal problems.
d) Measured TSH.
e) All of the above.
All of the above
All of the following are considered secondary causes of obesity except:
a) Prader-Willi Syndrome
b) Hypothyroidism
c) Depression
d) Drug-induced obesity
e) Excessive Caloric intake
Excessive Caloric intake
What are iatrogenic causes of obesity?
- Drugs that cause weight gain
- Hypothalamic surgery
What are dietary causes of obesity?
- Infant feeding practices
- Progressive hyperplastic obesity
- Frequency of eating
- High fat diets
- Overeating
What are neuroendocrine causes of obesity?
- Hypothalamic obesity: tumors, surgery, congenital
- Hypothyroidism
- Seasonal affective disorder
- Cushing's syndrome
- Polycystic ovary syndrome (PCOS)
- Hypogonadism
- Insulinoma
- Growth hormone deficiency
- Pseudohypoparathyroidism
What are social and behavioral factors that contribute to obesity?
- Socioeconomic status
- Ethnicity
- Psychological factors
- Restrained eaters
- Night eating syndrome
- Binge-eating
What are lifestyle causes of obesity?
- Enforced inactivity (post-operative)
- Aging
What are possible mechanisms by which drugs can induce weight gain?
– Increased energy intake due to interference with appetite-regulating neurotransmitters, especially serotonin
– Sedative and anticholinergic effects
– Reduced energy expenditure
– Increased insulin resistance
What drugs cause weight gain?
• Antidepressants: MAO inhibitors, Paroxetine, Escitalopram, Mirtazapine
• Lithium
• Antipsychotics: Olanzapine, Clozapine, Risperidone
• Antiepileptics: Carbamazepine, Valproate, Divalproate
• Insulin
• Oral hypoglycemic drugs: Sulfonylureas and PPAR agonists
• Glucocorticoids
• Antihypertensive agents: Beta-blockers
• Highly active anti-retroviral therapy
What things in an obese patient's history do you need to evaluate?
- History of weight gain
- Diet
- Exercise
- Sleep
- Weight loss attempts
- Medications
- Family history
- Symptoms of cardiac, respiratory, sleep apnea, joint disease, fertility, hypogonadism
What things in an obese patient's physical exam do you need to evaluate?
- Secondary causes of obesity
- Consequences of obesity
What are some common secondary causes of obesity?
- Cushing's disease
- Primary hypothyroidism
- Growth hormone deficiency
- Hypothalamic obesity (eg, Prader-Willi syndrome)
What complications do you need to screen for in an obese patient?
– Blood pressure
– Fasting lipid panel
– Hemoglobin A1c
– Liver tests
– Cancer risk
– Cardiac risk
– Sleep study
What labs should you evaluate in an obese patient?
– Thyroidtests
– Salivarycortisol
– Fasting glucose, insulin, C-peptide
– IGF-1
– MRI brain
Obesity results in development of diabetes by
a) Increasing susceptibility to infections that destroy beta-cells
b) Induces Cushing’s syndrome and thus developing diabetes
c) Inducing insulin resistance and increasing total body insulin requirements
d) Causes people to shun sun light, which results in vitamin D deficiency and hence diabetes
e) Causes depression which increases serotonin levels, resulting in diabetes
Inducing insulin resistance and increasing total body insulin requirements
What is the effect of insulin resistance on the heart?
Insulin resistance → inadequate insulin secretion → T2DM → coronary heart disease

Insulin resistance → compensatory hyperinsulinemia → syndrome X → coronary heart disease
Insulin resistance → inadequate insulin secretion → T2DM → coronary heart disease

Insulin resistance → compensatory hyperinsulinemia → syndrome X → coronary heart disease
How much weight does the average male (between 20-60) gain per year?
0.5 lb/year
A lesion in what part of the brain will lead to obesity?
VMH: Ventromedial Hypothalamus
A lesion in what part of the brain will lead to starvation?
LH: Lateral Hypothalamus
LH: Lateral Hypothalamus
What is the function of the Ventromedial Hypothalamus (VMH)?
Satiety center - tells you when you are full (if you lesion this area you will become obese)
What is the function of the Lateral Hypothalamus (LH)?
Hunger center - tells you when you are hungry (if you lesion this area you will starve yourself)
What is the effect of Leptin?
- Without leptin will become obese (not getting any feedback that you have enough fat stores, so you keep storing fat)
- With leptin will maintain a normal weight (tells your body you have enough fat tissue)
- Without leptin will become obese (not getting any feedback that you have enough fat stores, so you keep storing fat)
- With leptin will maintain a normal weight (tells your body you have enough fat tissue)
What hormones increase and decrease appetite?
- Ghrelin (increases appetite)
- Leptin (made in adipose to decrease appetite)
What are the determinants of energy expenditure? Percentage of total energy expenditure?
- Basal metabolic rate: 60%
- Thermic response to food (energy used to digest food): 10%
- Activity thermogenesis: exercise (10%) and non-exercise activity thermogenesis (20%)
How does resting and total energy expenditure compare in a lean person vs obese person?
Obese patients have higher resting and total energy expenditure (and if they lose weight it will be comparable to lean patients)
Obese patients have higher resting and total energy expenditure (and if they lose weight it will be comparable to lean patients)
How does sleep duration relate to BMI? Why?
The less sleep you get, the more likely you are to be obese (may have to do with abnormal hormonal regulation)
What is the minimal amount of weight loss that has been shown to be beneficial in prevention of type 2 diabetes in various clinical trials?
5-10%
Who is on the multidisciplinary team for treating obesity?
- Medical provider
- Dietician
- Exercise physiologist
- Behavioral psychologist
- Surgeon
What is the role of the medical provider for treating obesity?
- Differential diagnosis / complications
- Coordinate care
- Pharmacotherapy
What is the role of the dietician for treating obesity?
Develop appropriate diet
What is the role of the exercise physiologist for treating obesity?
Assess exercise capability and prescribe activity
What is the role of the behavioral psychologist for treating obesity?
Lifestyle changes, address addictive behaviors, mood disorders
What is the role of the surgeon for treating obesity?
Bariatric surgery
At what point is bariatric surgery recommended?
- For everyone with BMI >40
- For those with BMI 35-40 with co-morbidities
- For everyone with BMI >40
- For those with BMI 35-40 with co-morbidities
At what point is diet, exercise, and behavior therapy recommended?
- For everyone with BMI >30
- For those with BMI 25-30 with co-morbidities
- For everyone with BMI >30
- For those with BMI 25-30 with co-morbidities
At what point are medications recommended?
- For everyone with BMI >30
- For those with BMI 27-30 with co-morbidities
- For everyone with BMI >30
- For those with BMI 27-30 with co-morbidities
How do the popular diets compare in terms of efficacy?
They are all equally effective at losing weight, but most important factor is finding one they will stick with
What are the physical activity guidelines for Americans?
- >150 min (2.5 hours) per week of moderate intensity
OR
- >75 min per week of vigorous intensity aerobic physical activity

- Muscle strengthening involving all major muscle groups 2 or more days per week
What are the long-term FDA approved medications for patients with obesity?
- Orlistat
- Lorcaserin
- Phentermine / Topiramate
What are the short-term (<12 weeks) FDA approved medications for patients with obesity?
- Phentermine
- Diethylpropion
- Benzphetamine
- Phendimetrazine
What is the approximate average weight loss achieved with lifestyle changes?
2-8%
What is the approximate average weight loss achieved with pharmacotherapy?
5-20%
What is the approximate average weight loss achieved with surgery?
15-40%
What is the impact of weight loss on risk factors?
Achieved with ~5% weight loss
- ↓ HbA1c
- ↓ BP
- ↓ Total cholesterol
- ↑ HDL cholesterol

Achieved with ~10% weight loss
- All of the above
- ↓ Triglycerides
What kind of drug is Phentermine?
Sympathomimetic amin (Schedule IV)
- Approved for short-term use (12 weeks)
What is the effect of Phentermine?
5-7% weight loss (placebo subtracted)
- Approved for short-term use (12 weeks)
When is Phentermine contraindicated?
- Vascular disease
- Uncontrolled HTN
- Hyperthyroidism
- Glaucoma
- MAO-I
- Pregnancy
What are the adverse effects of Phentermine?
- Dry mouth
- Constipation
- Insomnia
- Nervousness, irritability
- Increased pulse
What is the mechanism of action of Amphetamines?
- Inhibits MAO
- Reverses DAT, SERT, and NET
**Suppresses appetite
- Inhibits MAO
- Reverses DAT, SERT, and NET
**Suppresses appetite
What is the effect of Orlistat?
3-5% weight loss (placebo subtracted)
What are the contraindications of Orlistat?
- Cholestasis
- Malabsorption
- Nephrolithiasis
What are the adverse effects of Orlistat?
- Diarrhea
- Loss of fat soluble vitamins (advise taking multivitamin before bedtime)
- Malabsorption of other meds (measure levels)
- Hyperoxaluria
- Rare causes of liver toxicity
What is the mechanism of Orlistat?
- Prevents fat digestion and absorption by binding to gastrointestinal lipases
- Works in lumen of intestine, minimally absorbed into body; binds to lipase to prevent digestion of TGs so that they are not absorbed (they just pass through)
- Can prevent absorption of up to 30% of the fat you eat
What is the effect of Lorcaserin?
3-5% weight loss (placebo subtracted)
What are the contraindications of Lorcaserin?
- Can't have concomitant use with other serotenergic and dopaminergic drugs (eg, SSRIs)
- Pregnancy (category X)
What are the adverse effects of Lorcaserin?
- Nausea
- Dizziness
- Headache
- Fatigue
- Mood effects
What is the mechanism of Lorcaserin?
Suppresses appetite
- 5-HT-2C receptor agonist → ↑ 5-HT bioavailability → POMC/CART → suppresses appetite
Suppresses appetite
- 5-HT-2C receptor agonist → ↑ 5-HT bioavailability → POMC/CART → suppresses appetite
What is the effect of Phentermine + Topiramate?
8-11% weight loss (placebo subtracted)
- Combining drugs so you can use less of each (to limit their side effects) but get greater weight loss by targeting two pathways
- Better than Phentermine alone (5-7% weight loss)
What are the contraindications to Phentermine + Topiramate?
- Known vascular disease
- Uncontrolled HTN
- Glaucoma
- MAO-I use
- Hyperthyroidism
- Pregnancy (category X)
What are the adverse effects of Phentermine + Topiramate?
- Constipation
- Altered taste
- Dry mouth
- Insomnia
- Paresthesias
- Fatigue
- Metabolic acidosis
- Nephrolithiasis
- Mood changes
What is the dosing protocol for Phentermine + Topiramate?
- Begin los dose for 14 days, then increase to mid dose
- If <3% weight loss at 90 days, discontinue or increase dose
- If <5% weight loss after 90 days at high dose, discontinue (with taper)
Case 1:
- Returns after 6 months, says he has lost ~10 lbs in 6 months
- Exercising 20-30 min for 3x/week
- Changed his eating habits "a lot"
- HbA1c is now 7.2%
- Orthopedic surgeon says he needs to lose 30-40 lbs more to get his knee replaced

Based on your new found knowledge, what do you think are Mr. DKs options for weight loss?
a) Since he has to loose weight, you can give him a combination of high dose phentermine with Locaserin.
b) Recommend him for a Jaw-wiring surgery
c) Recommend that he see a bariatric surgeon
d) Tell him that there is no hope, and he must suffer consequences of his obesity
Recommend that he see a bariatric surgeon
Why treat morbid obesity with surgery?
Medical management fails
Who is a candidate for bariatric surgery?
- BMI >40 or more than 100 lbs overweight
- BMI >35 with serious obesity related health problems (diabetes, HTN, obstructive sleep)
What are the "serious obesity related health problems" that can help you qualify for bariatric surgery with a BMI >35?
- Diabetes
- HTN
- Obstructive sleep
What are the restrictive surgical procedures for morbid obesity?
Restrictive procedures:
- Vertical banded gastroplasty - no longer used
- Laparoscopic adjustable gastric band (lap band)
- Laparoscopic sleeve gastrectomy
Restrictive procedures:
- Vertical banded gastroplasty - no longer used
- Laparoscopic adjustable gastric band (lap band)
- Laparoscopic sleeve gastrectomy
What are the characteristics of the "Lap-Band" procedure?
- Adjustable band around upper stomach
- Port for adjustment
- Decreases hunger
- Slower eating
- Average 40-70% loss of excess weight (therefore they still have 30-60% excess weight)
What are the pros of the "Lab-Band" procedure?
- No cutting stomach / intestine
- Adjustable
- No dumping syndrome
- Slightly less risk
- Shorter hospital stay
- Removable (unlikely)
- Less vitamin / mineral deficiency
What are the cons of the "Lab-Band" procedure?
- Slower weight loss (2-5 years)
- Frequent office visit (every 6 weeks)
- No dumping syndrome
- Implanted device
What is dumping syndrome?
- When you eat something hypo-osmolar (high in fat or high in sugar), it will sit in stomach and slowly be released into intestines
- If you didn't have pyloric muscle all of those would rush into small bowel (which isn't built to deal with that); to compensate it dumps lots of water into GI tract (quickly dehydrate)
- Become nauseated (may vomit); colon bacteria eat sugar in food and digest it and may cause diarrhea

This is good because it tells you not to eat lots of food with high sugar and high fat (negative reinforcement!)
What happens in the laparoscopic sleeve gastrectomy?
Divide stomach to leave a smaller pouch
- Leave it with one major artery (instead of the five)
- Remove 75-80% of stomach
- Keep pylorus (shouldn't have dumping syndrome
- Limits total amount of food
Divide stomach to leave a smaller pouch
- Leave it with one major artery (instead of the five)
- Remove 75-80% of stomach
- Keep pylorus (shouldn't have dumping syndrome
- Limits total amount of food
What are the malabsorptive surgical procedures for morbid obesity?
- Bilio-pancreatic diversion (BPD)
- Duodenal switch (also restrictive by removing part of stomach, and connect stomach to ileum, no pancreatic enzymes or bile to digest fat until very close to colon)
- Bilio-pancreatic diversion (BPD)
- Duodenal switch (also restrictive by removing part of stomach, and connect stomach to ileum, no pancreatic enzymes or bile to digest fat until very close to colon)
What is the gastric bypass surgery?
Roux-en-Y Gastric bypass:
- Divide stomach into two
- Divide small intestine into two and one limb comes up to part of the stomach
- Make 15-30cc pouch and connect to 15cm roux limb
Roux-en-Y Gastric bypass:
- Divide stomach into two
- Divide small intestine into two and one limb comes up to part of the stomach
- Make 15-30cc pouch and connect to 15cm roux limb
What causes weight loss in Roux-en-Y gastric bypass? How effective?
- Weight loss by restriction
- Get dumping syndrome (if you eat sugars and fats you will get diarrhea - negative reinforcement)
- 60-80% excess weight loss
What are the pros of the Roux-en-Y gastric bypass?
– Rapid wt loss (8-12 mo)
– Durable long term wt loss
– Restriction of volume
– Dumping syndrome
– Long-term data
– Treats GERD too
What are the cons of the Roux-en-Y gastric bypass?
– Restricted volume
– Dumping
– Anemia
– Vitamin / mineral deficiency
– Not reversible (but is revisable)
What vitamins / minerals might you be concerned about a patient getting after gastric bypass?
- B12 (no exposure to intrinsic factor - produced in body of stomach - can't be absorbed in ileum)
- Folate
- Iron (most predictable, because no exposure to acid)
- Ca2+, Vitamin D
How do you treat iron deficiency in patients with gastric bypass?
- Take iron supplement with vitamin C (acid)
- Give ferrous iron
Which type of bariatric surgery is most effective for losing excess weight loss?
- Duodenal switch (70% excess weight loss)
- Gastric bypass (62% excess weight loss)
- Gastric banding (48% excess weight loss)
- Duodenal switch (70% excess weight loss)
- Gastric bypass (62% excess weight loss)
- Gastric banding (48% excess weight loss)
Which type of bariatric surgery is most effective for treating diabetes?
- Duodenal switch (99% resolution)
- Gastric bypass (84% resolution)
- Gastric banding (48% resolution)
- Duodenal switch (99% resolution)
- Gastric bypass (84% resolution)
- Gastric banding (48% resolution)
Which type of bariatric surgery is most effective for treating hyperlipidemia?
- Duodenal switch (99% decrease)
- Gastric bypass (97% decrease)
- Gastric banding (57% decrease)
- Duodenal switch (99% decrease)
- Gastric bypass (97% decrease)
- Gastric banding (57% decrease)
What are the benefits of bariatric surgery?
- Excess weight loss
- Diabetes resolution
- ↓ Hyperlipidemia
- Resolves HTN
- Resolves sleep apnea
- Mortality
- Excess weight loss
- Diabetes resolution
- ↓ Hyperlipidemia
- Resolves HTN
- Resolves sleep apnea
- Mortality
What are the risks of Roux-en-Y gastric bypass surgery?
- Mortality (0.3%)
- Leak
- Blood clots
- Infection
- Stenosis
- Ulcer
- Hernia open
- Gallstones
What are the risks of lap band surgery?
- Mortality (0.1%)
- Erosion
- Blood clots
- Infection
- Device break
- Device slippage
- Hernia
- Gallstones
Case 2:
- 7yo female presents for annual well-child check-up
- Mom asks if child is at a healthy weight
- Picky eater who really loves pasta and rice
- Likes to ride her bike, and she is an avid reader
- She is otherwise healthy and has no symptoms during her visit

Which BMI is worrisome for a 7-year old child?
a) 15.5 kg/m2 (50th percentile)
b) 14.7 kg/m2 (25th percentile
c) 17 kg/m2 (80th percentile)
d) 21 kg/m2 (>95th percentile)
21 kg/m2 (>95th percentile)
What is the definition of being overweight in a pediatric patient?
BMI in 85th - 95th percentile
What is the definition of being obese in a pediatric patient?
BMI > 95th percentile
How common is pediatric obesity by ethnicity?
- African-American: 21.5%
- Hispanic: 21.8%
- Non-Hispanic: 12.3%
What are the risk factors for pediatric obesity?
– Rate of weight gain (not birth weight) in first year
– Both parents overweight = 80% of children obese
– 1/3 of overweight children = obese adults
What is the "thrifty gene" hypothesis?
- Fetal and early post-natal malnutrition early in life leads to epigenetic changes
- Patients who are small for gestational age or have intrauterine growth restriction may have changes in gene expression

- Modifies physiologic function to promote survival
- May predispose to disease later in life
- Higher rates of obesity, cardiovascular disease
What are the characteristics of childhood obesity?
- Epidemic – Widespread in population (adults and
children)
- Progressive – Childhood obesity becomes adult obesity
- Alters Development – Physically, emotionally, psychosocially
- Chronic disease – Lifelong morbidity accelerates “adult” disease into childhood
- Increases morbidity/mortality – First generation to have shorter lifespan than parents
How prevalent is being overweight / obese in children aged 2-5 years?
What is the obesity trajectory in pediatric populations?
- Phase I – Steady increase in childhood obesity
- Phase II – Emergence of serious obesity related comorbidities
- Phase III – Medical complications lead to life threatening disease—death in middle age
- Phase IV – Acceleration of obesity epidemic by transgenerational transmission
What are the complications of pediatric obesity?
- HTN (10-30% of children)
- Atherosclerotic process starts in childhood
- Insulin resistance → hyperinsulinemia → T2DM
- Early puberty
- Polycystic ovary syndrome (PCOS)
- Obstructive sleep apnea
- Depression, body image problems, eating disorders
What are the complications of adolescent obesity?
- 30% higher mortality rate as young and middle-aged adult
- Persistence of BMI into adulthood
- Increased risk of multiple co-morbidities, even if obesity did not persist
What are the expert committee recommendations for treating pediatric obesity?
- Assessment – BMI/nutrition/activity/readiness to
change
- Evidence based/evidence informed/expert opinion on
high risk behavior for obesity
- Stepwise approach to prevention and treatment
- Addressed obesity management in primary and tertiary care
- Multidisciplinary approach
- Family centered/parenting/motivational interviewing
How do you assess pediatric obesity?
- Calculate, chart, and classify BMI for all children 2–18 years of age at least yearly.
- Assess dietary patterns.
- Assess activity/inactivity.
- Assess readiness for change.
- Assess obesity related comorbidities.
- Assess ongoing progress.
What are the recommendations for behaviors to limit obesity risk?
– Limit consumption of sugar sweetened beverages.
– Limit TV (0 hours <2 years, <2 hours >2 years old).
– Remove TV from primary sleeping area.
– Eat breakfast daily.
– Limit eating out.
– Encourage family meals.
– Limit portion size.
What are the TV recommendations for children?
- 0 hours if <2 years
- <2 hours if >2 years
If a pediatric patient has a BMI in the 5-84 percentile, what recommendations should you make?
- Promote breast-feeding

Diet and physical activity:
- >5 servings of fruits and veggies
- <2 hours of screen time/day, no TV where child sleeps
- >1 hour of daily physical activity
- No sugar sweetened beverages
How do you prevent obesity in patients with BMI in 5-84 percentile?
Portions
– Age appropriate
– “Parents provide, child decides”
– 10–15 minute increments of exercise

Structure
– Breakfast
– Family dinners, no TV
– Limit fast food
– Outdoor time

Balance
– Food groups
– Limit refined sugar
– Screen time alternatives
How do you prevent obesity in patients with BMI in >85 percentile?
- Goal should be weight maintenance with growth that results in a decreasing BMI as age increases
- Monthly follow up for 3-6 months if no improvement go to stage 2
What do you look for on physical exam in pediatric patients that are obese?
Look for possible causes of obesity
What lab findings should you evaluate in a child with a BMI 85-94 percentile?
- Fasting lipid profile
- AST and ALT every 2 years
What lab findings should you evaluate in a child with a BMI >95 percentile?
- Fasting lipid profile
- AST and ALT every 2 years
- Fasting glucose
How should you communicate with a family with an overweight/obese child?
- Positive discussion of what healthy lifestyle changes families can make (evidence base)
- Allow for personal family choices.
- Have families set specific achievable goals and follow
up with these on revisits.
- Be aware of cultural norms, significance of meals and eating for family/community, beliefs about special foods, and feelings about body size.
- Motivational interviewing (what do you see as problems, things to improve?)
What are the characteristics of patients with Prader-Willi syndrome?
- MR
- Short stature
- Hypotonia
- Cryptorchidism
- Hyperphagia

Mutation at 15q11-q12
What can too rapid of weight loss lead to?
May result in gallstone formation
What can cause rapid weight loss?
- Very low calorie diet
- Late complication of bariatric surgery
In whom is rapid weight loss more common?
- Caucasians
- Women
How does the amount of bile mucin content change during rapid weight loss?
Bile mucin content increases 18-fold
How does the calcium content change in rapid weight loss?
Calcium content increases 40%
How can you prevent gall stone formation in patients with rapid weight loss?
Prophylaxis with ursodeoxycholic acid (used to treat (cholesterol) gallstones non-surgically)
How do you calculate a male's ideal body weight?
110 lbs + 5 lbs for each inch >5'
How do you calculate a female's ideal body weight?
100 lbs + 5 lbs for each inch >5'