How are you going to manage this patient’s Obesity?

 

Thank you for asking because I have a prepared answer I found on that great web site passthefracp.com

 

Firstly I would rule out reversible causes including,

 

Drugs such as anti-depressants, steroids, progestogens

Polycystic Ovary Disease

Hypogonadism

Growth Hormone deficiency

Hypothyroidism

Genetic syndromes such as Prader-Willi

 

Then I would assess co-morbidities such as the presence of,

                                                           

IHD/ PVD

Diabetes

Obstructive Sleep Apnoea

Hypercholesterolaemia/ Hypertriglyceridemia

Hypertension

 

But would be also interested in other vascular risk factors such as

Cigarette smoking

A family history

 

As well as other conditions related to obesity such as

Osteoarthirtis

Gallstones

Stress Incontinence

Gout

Increased risks of cancer – Colorectal, Prostate (ass with high fat intake), Breast, endometrial, ovarian

 

Then I would assess their degree of risk related to their BMI  and waist circumference (recognizing that > 102cm for males and 88cm for females put them at increased risk).

 

Then I would assess the patient psychological factors such as their readiness to change, support structures, understanding and discuss any potential barriers

 

Then I would recommend a 4 part approach

1)      Diet – Aim for 1-1,200 kcal / day for women and 1,200 to 1,600 kcal / day for men, aiming to create a deficit of 500-1000 kcal/ day with 30% or less fat, 15% protein and 55% CHO. Consider using Modifast if mobility limited or motivation poor or specific goal/ time frame in mind. With Modifast you can loose 12-20kg in 3 months and it’s a meal of 420 kcal/day with a slightly increased risk of gallstones and gout. An extra 2.25L oflow calorie fluid must also be given daily maybe with added fibre to avoid constipation.

2)      Physical therapy – Aiming for 30 minutes of moderate exercise on most, or all days of the week. Exercise which ises 150 kcal/day or 1000/ week e.g. gardening for 30-45 minutes, stairwalking for 15 mintues, walking 2.5 km in 35 mintues. Can also decreased sedentary time by leaving the bus stop 1 stop early, parking further than ususal from work and walkingup the stairs. Also seek to introduce new forms of physical activity. If mobility is an issue can consider upper body exercises such as hydrotherapy and raking leaves.

3)      Behavioural therapy – Seek to assess whether the weight loss has been sought on their initiative, assess the events leading toa desire to loose weight,  the patients understanding of the required treatment, how much weight  they expect to loose. Discuss risky situations and precipitants for eating and alternatives.

4)      Pharmacological – Up to a BMI of 35 without metabolic complications (e.g. NIDDM) everyone should get 3-6 months of lifestyle advice first (diet, exercise) before considering medication (orlistat, sirbutamine) and VLCD (modifast*). Above that, you need to exclude sleep apnoea as a high priority and initiate medication sooner rather than later. As a last resort try surgery which is the only modality shown to reduced morbidity from obesity.

 

Generally aim for a weight loss of 10% of body weight over 6 months with this sustained over 5 years. At a rate of approximately 1 kg/ week. If the paetints does not loose 2 kg in the first moth of therapy the likelihood of response is low. Remember that orlistat also improves diabetic control and reduces the need for diabetic meds. Also reinforce that compliance is very important. Finally, if asked a roast beef/ salad/ apple meal equals 300 kcal.

At a BMI of 40 and above it is important to achieve weight stabilization as patients gain 6-12kg/ year because of the immobility alone. Other drugs such as SSRIs may also be of benefit in the treatment of obesity (secondary to increased satiety) especially if depression is evident.

 

*Points about Modifast you need to know-

            Can have beneficial effecs on lipids and blood pressure as well

            Intake is 450 kcal/day

            Duration of treatment is usually 12-16 weeks, with weight loss about 2kg /week

            The initial phase is only Modifast and allowed foods moving to 1-2 normal meals

            Need to take at least 2 litre of fluid in addition to the Modifast

            Allowed foods include low joule jelly, strained broth and limited vegetables

            Side effects; dry skin hair loss, increased uric acid, increased hepatic enzymes

            Need regular follow-up

 

*Points about Sirbutamine you may need to know-

            Acts via B1 adrenergic and %HT receptors

            Side Effects of mild adrenergic effects such as dry mouth, insomnia and hypertension