Obesity and metabolic syndrome case 1.

1
Ketsia Vallon

Obesity and metabolic syndrome case 1.1

Ketsia Vallon

objectives

Identify methods to appropriately diagnose obesity and the metabolic syndrome Describe metabolic syndrome and the associated health consequences with obesity Describe the components of a succesful weight managemen program, including nutrition,physical activity and behavioral reccomendation Describe the efficacy of medicatios and surgical approaches to the treatment of obesity

Case study
Rose is a 44-year old management consultant who presents to her physician with elevated BP and obesity. She is an African American. She has tried to lose weight 12 times during the past 15 years. Rose states that her weight problems began after the birth of her first child. She understands the health consequences related to obesity, but is rather motivated to lose weight for cosmetic reasons

Past medical history

No cardiovascular disease Takes no medications , vitamins or herbal supplements Reports no sleep disturbances

Family history

Positive for obesity and overweight Brother and sister are overweight Mother is obese, hypertensive and had MI at age 67 Mother is not a diabetic but has recent elevated blood glucose Father is of normal weight

Obstetrical history

Rose had three full term healthy deliveries Gained 35 to 40 lbs. With each delivery and lost 20 lbs on average after each delivery She has never been able to reach her prepregnancy weight

Review of systems

Skin: no rashes or unusual pigmentation HEENT: no visual complaints Neurologic: no headeache, tremors, seizures,or depression Endocrine: normal menses, no heat or cold intolorence Cardiovascular: normal heart rate and rhythm. Joints: no swelling, heat, or redness

Review of systems

Skin: no rashes or unusual pigmentation HEENT: no visual complaints Neurologic: no headeache, tremors, seizures,or depression Endocrine: normal menses, no heat or cold intolorence Cardiovascular: normal heart rate and rhythm. Joints: no swelling, heat, or redness

Physical examination

Vital signs temp 36.9 C Heart rate 88 BPM BP: 135/88 mmHg height 5'3 weight 20lbs BMI 36.8kg/m2 waist circumference; 38

Exam

Physical examination

obese women in no acute distress; no cushingoid features; no hirsutism,;no dorsal, cervical or supraclavicular fat

Skin: no striae, acanthosis nigricans HEENT: unremarkable Clear chest Heart: normal rhythm Abdomen: obese, no organomegaly

Physical examination (cont.)

Total calories: 2691Kcal protein:94g (14% of cal) fat:90g (30% of cal) saturated fat: 33g (11% of cal) Mono saturated Fat: 21g (7%) cholesterol: 334mg carb:355g (53%of cal) fiber:13g Na+ 4800mg Ca++ 601mg

Case question 1
How are overweight and obesity clinically assessed in this patient?

Through BMI Intra-abdominal adipose tissue (waist circumference) correlates with cardiovascular, stroke, dyslipidemia, hypertension, type 2 diabetes Rose's waist circumference is 38 and her BMI is 36.8kg/m2

What are the medical risks associated with obesity?

Case question 2

Increase risk of cardiovascular disease Stroke, hyperlipidemia, cholecystitis Certain types of cancer Physical stress are evident with rose such as snoring (sleep apnea risk) borderline high LDL high glucose, sedentary lifestyle ( risk of type 2 diabetes) High blood pressure High triglyceride

Does rose meet the criteria to diagnose metobalic syndrome?

Case Question 3

According to the National Cholesterol Education program ( Adult Treatment PanelII guidelines, patients can be diagnosed with metabolic syndrome if they exhibit any three of the following condition:

Case question 4
What are the appropriate treatment goals for rose?

Weight reduction 10% reduction would reduce blood pressure and serum glucose, LDL and subsequently lower risk of stroke heart disease and diabetes

increased physical activity a predictor of long-term wieght maitenance lowers BP lowers risk of cardiovascular disease and osteoporosis

Case question 4
What are the appropriate treatment goals for rose?

Weight reduction 10% reduction would reduce blood pressure and serum glucose, LDL and subsequently lower risk of stroke heart disease and diabetes

increased physical activity a predictor of long-term wieght maitenance lowers BP lowers risk of cardiovascular disease and osteoporosis

Case question 5

Describe the biochemical and metabollic effects of high-protein, low carbohydrate diet?

Physical activity goals

Rose is a busy marketing manager with little to exercise. Any exercise program may need to address this issue.

Walking after dinner could be a start Walking during work breaks

Realistic weight goal

Current weight is 208lbs and 63 If she adheres to safe dietary reccomdation she could safely lose 10 to 20 lbs in 6 months. After attaining this weight goal, a new weight goal could be entertained a potential reduction to 175lbs is ideal

Pharmacology options

intervention to facilitate weight loss include drugs that enhances satiety, decrease fat absorption, and decrease appetite Two drugs Meridia (sibutramine) Xenical (orlistat)

Next case

Case study 7.1 alcohol and vitamin deficiencies

Objectives explain how excessive alcohol consumption contributes to nutritional deficiencies Describe the biochemical and physiologic abnormalities that occur with excessive alcohol intake assess a patient's alcohol intake during a routine social history

Describe the nutritional recommendations for patients who consume alcohol

Case overview

52 year-old car salesman present for a yearly physical. Reports fatigue, burning in his feet, decreased memory, and heartburn. The patient also reports weight gain and increased waist size, decrease endurance when exercising. No blurred visions, headaches, night sweats or hearing loss.

Past medical history

No prior heart disease, stroke, or peripheral vascular disease. Has liver damage but received no treatment No current medications No food or drug allergies.

Social history

Usually consumes 3 healthy meals daily Poor appetite for the past week Smokes 1 pack of cigarette per day for 30 years

Family history

No heart diseases, stroke, high cholesterol, No lipd or neurologic disorders

Family history

No heart diseases, stroke, high cholesterol, No lipd or neurologic disorders

Review of systems

General :lethargic, decreased appetite, recent bloating. GI: no vomiting or diarrhea Neurologic: no seizures, tinnitus, syncope reports some memory loss.

Physical examination
Vital signs

Physical examination
Exam

Laboratory data

Lab results

Case question 1

What additional information is important to obtain from a patient who presents with these symptoms? Once a patient admits to drinking, the CAGE test should be used.

Case question 2

What are the biochemical consequences of excessive alcohol consumption? Can cause metabolic acidosis by intefering with the oxidation of acetyl CoA in the TCA cycle

Increase in triglyceride levels due to ketoacidocic state

Case question 3

What are the nutritional consequences of excess alcohol consumption? Alcohol provides 7kcal/gram provides no protein, vitamins or mineral drinking decrease appetite alcohol consumption can disrupt the GI mucosa and leads to absorption problems

Question 3 (cont)
Alcohol consumption result in thiamin defficiency. Inadequate thiamin defficiency leads to lactate production which contributes to lactic acidosis

Thiamin deficiency can manifest as anorexia, irritability, fatigue, decrease memory, peripheral neurophathy, confusion and tachycardia

Question 3 (cont)

Chronic alcohol consumption has also been associated with folate and B12 deficiencies

Case Question 5

What evidence from the medical history, physical exam, and lab result suggest complications of alcohol and nutritional deficiencies decreases lower limb reflex and sensation thiamin deficiency fatigue (lab results suggest anemia) high corpuscular volume (presence of large RBC's) due to follate and B12 deficiency

Case Question 6

What does the serum albumin level indicate? May be an indication of depleted protein levels liver disease is associated with low albumin but usually in end stage liver disease

Case Question 7

What additional lab test would you perform before giving folate supplement? Serum RBC folate and vitamin B12 should be evaluated alcoholics are not usually B12 deficient but this patient presents with megablastic anemia, hence B12 is low giving folate without B12 will help the anemia and mask other problems related to B12 alone (neurologic problems)

Additional test rerults

Results patient values vitamin B12: 520pg/ml serum folate: 2ng/ml RBC folate: 90ng/ml normal values 220-290 pg/ml 3-17bg/ml 280:903ng/ml

reccomendations

The patient should receive thiamin, folate and multivitamin supplements Patient should be advised to eliminate drinking alcohol and enroll in an appropriate therapy program

Case 13.1 colon cancer and post-operative sepsis Objectives

Describe the appropriate parental nutrition recommended for colon cancer. Assess the nutritional status of a critically ill patient Identify clinical and metabollic parameters used to monitor parental nutrition Recognize the adverse effects of undernutrition and the associated benefits of providing appropriate nutrition support Recognize the benefits of parental nutrition in a malnourished , critically ill, surgical patient

Case study AJ is a 73-year old Mexican man who presents with a 72-hour increasing radiating abdominal pain. He repors nausea and vomiting of GI contents at least 5 times in 3 days. He also reports of liquid greenish stool at least 8 time. He has been losing weight without trying for the past 6 months.

Past medical history

Stroke 2 years ago with resulting weakness in his right leg Currently takes coumadin and digoxin No food or drug allergies Appendectomy three years ago

Social history

Retired Heavy drinker in the past (1liter/day), but quit drinking 10 years ago. Smoked 20 cigarretes daily but also qiut 10 years ago.

Review of systems

Overall system was unremarkable except for nausea, abdominal pain, liquid stools, vomiting and unintentional weight loss.

Physical examination
Vital signs

Temp: 38*C Heart rate: 112 BPM Respiration: 23 BPM BP: 100/60 mmHg Height: 5'6 Weight: 99lbs (was 136 a year ago) 132-99/132 = 25% loss BMI: 16

Physical examination Vital signs

Temp: 38*C Heart rate: 112 BPM Respiration: 23 BPM BP: 100/60 mmHg Height: 5'6 Weight: 99lbs (was 136 a year ago) 132-99/132 = 25% loss BMI: 16

Physical examination Vital signs

Temp: 38*C Heart rate: 112 BPM Respiration: 23 BPM BP: 100/60 mmHg Height: 5'6 Weight: 99lbs (was 136 a year ago) 132-99/132 = 25% loss BMI: 16

Physical examination
Exams

General:Thin male in distress Skin: pale, cold and dry HEENT: Anicteric Cardiac: regular rate and rhythm Pulmonary: decreased sounds bilateraly, with rales Abdomen: tenderness, distended, no bowel sounds Extremeties: paresis of the right leg, no edema Neurologic: awake, alert, non-focal, no asterixtics

Physical examination Exams

General:Thin male in distress Skin: pale, cold and dry HEENT: Anicteric Cardiac: regular rate and rhythm Pulmonary: decreased sounds bilateraly, with rales Abdomen: tenderness, distended, no bowel sounds Extremeties: paresis of the right leg, no edema Neurologic: awake, alert, non-focal, no asterixtics

Radiographic studies

Abdominal x-rays shows severe loop distention of the small bowel in the RUQ with no air in the rectum. Abdominal sono reveals distended loops of small intestine. No evidence of gallstones. Bile ducts and the liver are normal

Laboratory data

data

Hospital course and therapy

Nasogastric tube was placed to resolve nausea and vomiting NPO restriction Nausea and vomiting resumed after 24 hours of hospitalization Exploratory laparotomy procedures revealed a 3.9 cm tumor in the sigmoid colon Colectomy and ileostomy was performed Histopathlogy reported adenocarcenoma of the colon The patient's serum creatine dropped to 1.2mg/dl There was no renal failure.

Case question 1 List the patient's possible medical problems.

Bowel obstruction Mesenteric thrombosis (stroke history) Severe electrolyte imbalance (hyperkalemia, high BUN and creatine) Bilateral Pneumonia Unintentional weight loss and severe undernutrition

Case question 2
What are the possible etiologies of AJ's bowel obstruction?

Hernia, adhesions, intussusception, and cancer In older patients, diverticulitis and volvulus may be causes of obstruction.

Case question 3
What additional evidence from AJ's physical examination could be used to assess his nutritional status prior to initiating parental nutrition?

Thin appearance, weight loss Decreases food intake Low albumin

Case question 4
Why is parenteral nutrition the most appropriate form of intervention at this point in AJ's clinical course?

The patient has malnutrition inflamatory metabolism, abdominal sepis, cancer and impaired intestinal function. Parenteral nutrition should be used to prevent further undernutrition.

Case question 5
Calculate AJ's resting energy expanditure (REE).

66+13.7(weight in kg) +5(height in cm) 6.8(1ge) 66+13.7(45kg) +5(170cm) -6.8(73cm) =1035Kcal/day

Quetsion 5 (cont)
calculate AJ's protein goal and max carbohydrate and lipid oxidation rates.

Protein goals=weightX1.3g/kg =45kg X 1.45g/kg =65g/day Maximum carbohydrate oxidationrate is 5 to 7 mg per minute in hospital patients but parental carbohydrate infusion should not exeed 4mg per minute in the critically ill Maximum lipid oxidation rate is 2.5 grams per kg per day and fat has 9Kcal/gram

Question 5 (cont)
How much dextrose and lipid should be ordered in the PN?

Dextrose should be 660kgcal per day (3.0 mg/kg/min) Lipid should be 1 gram for each kg of body weight

Case question 6
What biochemical laboratory data should be used to monitor AJ while he is on PN?

Na+, K+, Cl- , CO2, BUN, creatinine, Mg++, phosphorus, and glucose should be monitored daily Liver funtion test and Albumin weekly Transferin and triglycerides every few weeks 24-hour urea test weekly

Question 7
AJ has advanced to oral diet, how should feeding begin?

With clear liquid, and gradually advance as can be tolerated. PN should be discontinued as soon as AJ start to get 75 percent of his requirements from oral diet.

Thank you