# Internal Medicine 16: 45-year-old male who is overweight

Author/Editor: Nora L. Porter MD

# INTRODUCTION

##### HISTORY

You are working in the ambulatory internal medicine clinic with Dr. Simon. He asks you to see Mr. Harrison James.

According to the medical record, Mr. James is a 45-year-old male whose last physical exam was about a year and a half ago. No problems were noted. No laboratory results are in the record.

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The vital signs recorded by the nurse today include:

Vital signs:

• Pulse is 74 beats/minute

• Blood pressure is 124/68 mmHg

• Weight is 100 kg (220 lbs)

• Height is 170 cm (67 in)

You note that his weight at his last visit was 94.35 kg (208 lbs).

TEACHING POINT

# How to Calculate Body Mass Index

• Divide weight (in kilograms) by height (in meters) squared: BMI = kg/m.

• BMI can also be calculated as weight in pounds divided by height in inches squared with the result then multiplied by 703.

• Many on-line tools, as well as paper-based charts, are available to assist you in calculating BMI.

# Question

What is Mr. James’ body mass index (BMI)?

The suggested answer is shown below.

Letter Count: 2/1000

34.5 kg/m2

Mr. James’ BMI is 34.5 kg/m2.

You note that his previous BMI was 32.6 kg/m2.

# Question

What is your interpretation of Mr. James’ BMI? Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

• A. Morbidly obese

• B. Normal weight

• C. Obese

• D. Overweight

• E. Underweight

> The correct answer is C. Mr. James has class I obesity. The term “morbid obesity” is no longer used, and has been replaced by “severe obesity” or “class III obesity.”

TEACHING POINT

# Interpreting the BMI

In adults, BMI correlates reliably with percentage of body fat and is useful in determining risk for certain poor health outcomes. Because of this, most experts recommend that all adults be screened for obesity using the BMI.

 BMI Interpretation < 18.5 Underweight 18.5-24.9 Normal weight 25-29.9 Overweight > 30 Obese

Additionally, there are three classes of obesity:

• Class I: BMI 30–34.9

• Class II: BMI 35–39.9

• Class III: BMI ≥ 40

The National Institutes of Health publishes a table of body mass indices that can assist you and your patients in determining whether they are overweight, and also how much weight they would need to lose to reach a recommended weight for their height.

##### HISTORY

You introduce yourself to Mr. James and ask what brings him to the office today. He replies, “I just thought I should have a check-up.”

You ask if he has any concerns, and he says, “No, I’m doing great!”

You feel a bit uncomfortable addressing the issue of weight with Mr. James, but you know that it is important for his health, so you begin:

TEACHING POINT

# Additional Components of the History for Patients with Obesity

A thorough history is essential to knowing how to counsel a patient with obesity.

Weight history

• Begin in childhood and include any significant weight changes, as well as any family history of weight-related problems and complications. Ask about events associated with weight gain or changes in dietary patterns.

• Ask about prior attempts at weight loss (information about previous diets tried, weight loss achieved, reasons for stopping, and subsequent weight gain should be obtained). This information can be very helpful in counseling patients about weight loss.

• Obtain information about barriers encountered in prior weight loss attempts to help the patient plan strategies to avoid or deal with those barriers in the future.

Dietary history

• Types and quantities of foods eaten

• Types and quantities of beverages consumed, including soft drinks, fruit juices, and any sweeteners or flavorings added to coffee or tea

• Composition of meals (amounts of protein, carbohydrates, fat)

• Timing of meals

• Triggers for eating (hunger, environmental, and emotional)

History of physical activity

This is needed to determine caloric requirements and advise about increasing physical activity. Include:

• Activities associated with work

• Leisure time activities

• Structured exercise

Alcohol, tobacco, and other substance use

• Alcohol consumption is an often overlooked source of dietary calories and excess alcohol consumption may impair judgment and lead to overeating.

• Marijuana is an appetite stimulant and may be associated with weight gain.

• Tobacco use is a significant risk factor for coronary heart disease (CHD). All patients who smoke, especially those with other CHD risk factors such as obesity, should be advised to stop smoking and offered assistance with quitting. Individuals who stop smoking frequently increase their caloric intake and gain weight. Smoking cessation counseling should include advice about minimizing the associated weight gain and reassurance that the health risks of smoking far outweigh the health risks of the small weight gain that may accompany smoking cessation.

Psychosocial stress

Recent changes in an individual’s employment or personal life may lead to changes in diet or physical activity, causing weight gain.

Medication history

A thorough medication history, including nonprescription supplements, is important, as a number of medications have been identified as promoting weight gain. Glucocorticoids, tricyclic antidepressants, some selective serotonin reuptake inhibitors, certain antipsychotics and antiepileptics, insulin, and some hormonal agents can contribute to obesity.

TEACHING POINT

# Medical History for Patients with Obesity

1. Ask about symptoms of medical conditions that might predispose patients to secondary obesity.

• Cushing syndrome (easy bruising, hyperpigmentation, muscle weakness)

• Hypothyroidism (fatigue, cold intolerance, constipation)

2. Ask about symptoms of medical conditions associated with obesity, including symptoms of cardiovascular disease.

• Sleep apnea (snoring, daytime somnolence, and morning headaches)

• Cardiovascular disease (chest pain or pressure, dyspnea, or changes in exercise tolerance)

• Cerebrovascular disease (changes in vision or focal neurologic symptoms)

• Peripheral vascular disease (claudication)

• Diabetes (polydipsia, polyuria)

The risk of developing coronary heart disease (CHD) or other vascular disease (cerebrovascular or peripheral vascular disease) increases as the number of risk factors increases. Any patient identified as having a CHD risk factor needs to be assessed for other risk factors. Modifiable and treatable risk factors—such as diabetes mellitus, hypertension, and dyslipidemia—need to be identified and treated to decrease the risk of developing CHD or other vascular disease.

Family History

Mr. James has no family history of diabetes, but his father, two brothers, and one sister have high blood pressure and hyperlipidemia. His father had a heart attack at age 68.

Review of Systems (ROS)

He has no chest pain, pressure, or tightness; no shortness of breath or changes in exercise tolerance; no edema; no leg pain with walking or at rest; and no headaches, blurry vision, or focal neurologic symptoms. He feels tired frequently but does not fall asleep easily during the day. He sleeps well at night and has never been told he snores. His review of systems is otherwise unremarkable. He takes no medications.

# A DIFFERENTIAL-DRIVEN PHYSICAL EXAM

##### PHYSICAL EXAM

Next, you move on to the physical examination. You know your physical examination should focus on findings suggestive of coexisting risk factors of established vascular disease.

You take Mr. James’ blood pressure and find it is 122/64 mmHg.

# Question

Which of the following physical findings indicate risk factors for coronary heart disease? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• A. Buffalo hump

• B. Carotid bruits

• C. Diminished peripheral pulses

• D. Increased waist circumference

• E. Roth spots

• F. Striae

• G. Xanthelasma

> The correct answers are B, C, D, G. For more on the correct answers, see the Teaching Point below.

Findings such as buffalo hump (A), striae (F), moon facies, and bruising can be seen in states of cortisol excess. Depressed tendon reflexes or goiter may be seen in hypothyroidism. These are secondary causes of obesity.

Roth spots (E) are retinal hemorrhages with pale centers, typically seen in bacterial endocarditis.

TEACHING POINT

# Physical Findings Indicating Risk for CHD

Numerous findings on physical exam can be clues to underlying risk factors for CHD.

Findings of hypercholesterolemia:

• Plaques or nodules composed of lipid-laden histiocytes, called xanthelasmas (on the eyelids) and xanthomas (on extensor tendons)

Findings of vascular disease:

• Carotid bruits

• Diminished peripheral pulses

• Hypertension

• Increased abdominal aortic size (the diameter of a normal abdominal aorta should be less than 2 cm)

Other findings indicating increased risk of CHD:

• Increased waist circumference (> 40 inches in males, > 35 inches in females)

##### TEACHING

Aside from his weight and an increased waist circumference of 42 inches, Mr. James’ physical examination is normal. You tell Mr. James you need to discuss his case with Dr. Simon and step out of the room.

After presenting Mr. James’ history and physical findings, you share your concern about his weight gain with Dr. Simon. Together you review the adverse health effects of obesity and the underlying metabolic changes.

TEACHING POINT

# Metabolic Effects of Obesity

Obesity increases

• insulin resistance

• low-density-lipoprotein (LDL) cholesterol

• very-low-density-lipoprotein (VLDL) cholesterol, and

• triglycerides

Obesity decreases

• High-density-lipoprotein (HDL) cholesterol

Health Risks Associated with Obesity

The metabolic effects of obesity increase the risk of a number of common medical conditions, including:

• Type 2 diabetes mellitus

• Hypertension

• Dyslipidemias

• Coronary heart disease

• Stroke

• Peripheral vascular disease

Other adverse health outcomes associated with obesity:

• Congestive heart failure

• Atrial fibrillation

• Chronic back pain

• Osteoarthritis

• Venous thromboembolic disease

• Cholelithiasis

• Nonalcoholic fatty liver disease

• Gastroesophageal reflux

• Obstructive sleep apnea

• Polycystic ovary syndrome (PCOS)

Patients with a BMI ≥ 40 also have higher death rates from a number of cancers, including:

• Non-Hodgkin lymphoma

• Multiple myeloma

• Cancers of the esophagus, stomach, colon, rectum, liver, gallbladder, pancreas, kidney, uterus, and ovary.

Overall, greater BMI is associated with increased all-cause mortality.

# DISCUSSING METABOLIC SYNDROME

##### TEACHING

Having established that obesity is a common condition associated with a lot of serious medical problems, Dr. Simon then asks, “Do you think Mr. James could have metabolic syndrome?”

# Question

Which of the following are components of metabolic syndrome? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• A. Impaired fasting glucose

• B. Increased blood pressure

• C. Increased BMI

• D. Increased low-density lipoprotein (LDL) cholesterol

> The correct answers are A, B.

TEACHING POINT

# Metabolic Syndrome

Definition

The National Cholesterol Education Program defines metabolic syndrome as any three of the following five:

• Fasting plasma glucose ≥ 100 mg/dL (or on medical therapy for hyperglycemia)

• BP ≥ 130/85 mmHg (or on medical therapy for hypertension)

• Triglycerides ≥ 150 mg/dL, non-fasting (or on medical therapy for hypertriglyceridemia)

• High density lipoprotein (HDL) cholesterol < 40 mg/dL for men, < 50 mg/dL for women (or on medical therapy for low HDL cholesterol)

• Abdominal obesity (waist circumference > 40″ for men, > 35″ for women)

Mechanism

Insulin resistance is believed to be the underlying mechanism of metabolic syndrome. There is some controversy about the existence of a metabolic syndrome, as opposed to a collection of independent risk factors; however, this distinction should not discourage appropriate risk factor management and risk reduction.

Treatment

Aggressive lifestyle modification (dietary modification, physical activity, weight loss, and smoking cessation) is first-line therapy for metabolic syndrome. Medication is often indicated if lifestyle modification is unsuccessful.

Coexisting disorders

Metabolic syndrome is also associated with:

• Diabetes mellitus

• Cardiovascular disease

• Nonalcoholic fatty liver disease

• Hepatocellular carcinoma

• Cholangiocarcinoma

• Chronic kidney disease

• Obstructive sleep apnea

• Hyperuricemia

• Gout

• Polycystic ovary syndrome

# References

Alberti KG, Eckel RH, Grundy SM, et al. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation. 2009;120(16):1640-1645.

International Diabetes Federation. Consensus worldwide definition of the metabolic syndrome. http://www.idf.org/our-activities/advocacy-awareness/resources-and-tools/60:idfconsensus-worldwide-definitionof-the-metabolic-syndrome.html. Accessed September 3, 2020.

# ORDERING APPROPRIATE LABS

##### TESTING

“Now that you’ve completed Mr. James’ history and physical,” Dr. Simon asks, “would you like to order any tests?”

# Question

Which laboratory tests would you like to obtain for Mr. James? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• A. Complete blood count

• B. Hemoglobin A1c

• C. Lipid profile

• D. Renal function (BUN and creatinine)

• E. Serum cortisol

• F. None at this time

> The correct answers are B, C.

You decide you should check Mr. James’ fasting glucose and cholesterol.

Other options:

Complete blood count (A) and renal function (D) do not need to be checked in this healthy, asymptomatic 45-year-old male. Some experts advocate measuring transaminases to screen for hepatic steatosis in obese patients. To date, there is no evidence of improved clinical outcomes from such screening.

Mr. James does not have any symptoms or physical findings suggestive of an endocrine disorder causing his obesity. If a disorder such as hypothyroidism or Cushing syndrome were suspected, additional laboratory evaluation would be indicated.

TEACHING POINT

# Obesity Evaluation for Coexisting Risk Factors

Patients with obesity should be evaluated for coexisting risk factors, including diabetes and dyslipidemia.

Diabetes can be diagnosed with blood glucose or hemoglobin A1C:

1. Blood glucose

• A fasting blood glucose ≥ 126 mg/dL (≥ 7.0 mmol/L) confirmed on repeat testing or

• A random blood glucose ≥ 200 mg/dL (≥ 11.1 mmol/L) with symptoms of hyperglycemia

• A fasting blood glucose between 100 and 125 mg/dL (5.6 and 7.0 mmol/L) indicates prediabetes

2. Hemoglobin (Hb) AIC

• > 6.5% = diabetes

• 5.7–6.4% = prediabetes

Recommendations for screening for lipid disorders:

• 2019 Guidelines on the Primary Prevention of Cardiovascular Disease from the American Heart Association and the American College of Cardiology recommend assessing for lipid disorders at least every 4 to 6 years in adults 20 to 39 years of age. For adults aged 40 to 75, screening should be repeated every 3 to 5 years. Screening may be performed by measuring total and HDL cholesterol levels.

Epidemiologic studies have consistently shown a strong relationship between levels of total and LDL cholesterol and the rate of new onset CHD.

See the associated reference ranges in conventional and SI units.

# References

Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation. 2019 Jun 18;139(25):e1182-e1186]. Circulation. 2019;139(25):e1082-e1143.

U.S. Preventive Services Task Force. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication. November 13, 2016. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/statin-use-in-adults-preventive-medication. Accessed September 3, 2020.

# CONDUCTING BEHAVIORAL COUNSELING

##### TEACHING

Before you return to the exam room to talk with Mr. James together, Dr. Simon tells you, “Behavior change is one of the hardest things we ask our patients to do, but it’s essential for weight loss. Making major changes in diet and physical activity, and sustaining them long-term, takes a lot of education and motivation. You can use the five A’s to help the patient make and meet his goals. You’ve already done the first one.”

TEACHING POINT

# How to Approach Behavioral Counseling

The Five A’s of Behavioral Counseling

1. Assess the patient’s dietary practices and related risk factors.

2. Advise the patient to change dietary practices.

3. Agree with the patient on goals.

4. Assist the patient in changing dietary practices or addressing motivational barriers.

5. Arrange follow-up, support, and/or referral for the patient.

In the office setting, brief counseling about dietary change may be all that is practical, although it may be supplemented with educational materials given to the patient.

Initial counseling should focus on the health risks of an unhealthy diet and assessing the patient’s willingness to change dietary practices. Topics such as healthy food choices, portion sizes, calorie requirements, and barriers to change need to be addressed as well.

Regular follow-up to address these and other issues as well as a possible referral to a nutritionist, dietitian, or health educator are important components in achieving sustained dietary behavior change.

# MANAGING OBESITY

##### MANAGEMENT

You and Dr. Simon return to see Mr. James together. Dr. Simon reviews the history, checks your exam, then says, “Mr. James, we are concerned about your weight.”

You tell him obesity increases his risk of high blood pressure, high cholesterol, diabetes, heart disease, stroke, arthritis, and cancer.

You give Mr. James an information sheet on healthy food choices and the importance of daily physical activity along with a list of dieticians he may contact for more detailed information.

You bring up the subject of barriers to weight loss. “Weight loss is one of the hardest things patients try to do. It involves a lot of changes in your day-to-day activities, breaking old habits, and learning new ways of doing things.

You reassure him, “Even though those things make it seem really hard for you to change, just identifying some of the problems you might run into is a great first step in figuring out how to solve them.”

# FOLLOW-UP CLINIC VISIT

##### CARE DISCUSSION

Two weeks later, Mr. James returns for a follow-up visit. You learn from the chart that Dr. Simon had called Mr. James to review his cholesterol test results and Mr. James requested to come to the clinic to discuss the results in more detail.

Dr. Simon shows you Mr. James’ laboratory report and asks you to review the results and think about what you would like to do next.

Fasting laboratory test results:

 Lab Values: Conventional: SI: Total cholesterol 206 mg/dL 5.34 mmol/L Triglycerides 136 mg/dL 1.5 mmol/L HDL 38 mg/dL 0.98 mmol/L LDL 141 mg/dL 3.65 mmol/L A1c 5.5%

See the associated reference ranges in conventional and SI units.

The nurse’s note reveals that today his blood pressure is 132/72 mmHg and his weight is 100.5 kg (221 pounds; a one-pound weight gain since his last visit). He feels well and has no new concerns.

You review the ACC/AHA guidelines on hypertension and note that with his systolic blood pressure over 130 mmHg he is technically in the stage 1 hypertension range. Since this is only one measurement, it would need to be confirmed on at least two more occasions before making the diagnosis. You make a note to discuss a home blood pressure monitoring device with the patient and Dr. Simon.

You review the ACC/AHA guidelines to determine the best way to address Mr. James’ cholesterol and realize you need to use the Pooled Cohort Equation to calculate his 10-year risk of ASCVD.

TEACHING POINT

# Recommended Hyperlipidemia Management

Lifestyle modifications are important in decreasing risk of atherosclerotic cardiovascular disease (ASCVD), irrespective of pharmacologic treatment.

There are four groups of patients who are most likely to benefit from statin therapy:

ASCVD statin benefit groups

1. Current clinical ASCVD

2. LDL cholesterol > 190 mg/dL

3. Diabetes (type 1 or 2) age 40-75 years with LDL > 70 mg/dL

4. Estimated 10-year ASCVD risk by Pooled Cohort Equations > 7.5%.

For more information about managing lipid disorders, see the Aquifer Cholesterol Guidelines module, and for more on managing hypertension, see the Aquifer Hypertension Guidelines module, both of which are available here.

# Question

What is Mr. James’ 10-year risk of ASCVD?

The suggested answer is shown below.

Letter Count: 120/1000

Mr. James’ 10-year risk of ASCVD is 3.2%, meaning that about 3 out of 100 people with this level of risk will have a stroke or myocardial infarction in the next 10 years.

TEACHING POINT

# Pooled Cohort Equation

The Pooled Cohort Equation predicts atherosclerotic cardiovascular events that are reduced by statin therapy. However, some have questioned the accuracy of the calculator. Concerns have been raised that it may overestimate risk in some patients, leading to overtreatment, while underestimating risk in others, especially those with a strong family history of cardiovascular disease.

# DISCUSSING DYSLIPIDEMIAS

##### TEACHING

“When you see cholesterol levels that are very high, you should also think about secondary causes,” Dr. Simon advises you.

You and Dr. Simon discuss some of the causes of dyslipidemias.

TEACHING POINT

# Causes of Secondary Dyslipidemias

Many dyslipidemias are familial, but there are other medical conditions that can cause dyslipidemias, and a number of medications that can adversely affect lipids.

• Type 2 diabetes mellitus and insulin resistance are associated with hypertriglyceridemia and low HDL cholesterol.

• Cholestatic or obstructive liver disease, such as primary biliary cirrhosis, may lead to elevated total cholesterol levels and xanthomata.

• Nephrotic syndrome causes high serum total and LDL cholesterol concentrations as well as triglycerides due to increased hepatic production and diminished lipid catabolism.

• Hypothyroidism causes high LDL cholesterol concentrations as well as hypertriglyceridemia.

• Acute hepatitis can cause hypertriglyceridemia.

• Alcohol can cause hypertriglyceridemia.

• Thiazide diuretics, beta-blockers, oral estrogens, and protease inhibitors can cause modest changes in serum lipid concentrations.

Patients with LDL cholesterol ≥ 190 should be evaluated for secondary causes of their dyslipidemia.

# LIPID-LOWERING MEDICATIONS

##### THERAPEUTICS

Dr. Simon says, “We have to balance Mr. James’ cholesterol level and his risk factors when we decide whether to start treatment. Although Mr. James does have some risk factors, his overall risk of developing CHD in the next 10 years is still low, less than 7.5%.” Dr. Simon then asks you,

# Question

Dr. Simon asks you, “If Mr. James did need medication, which lipid-lowering medication would you begin?” Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

• A. Bile acid sequestrant (e.g., cholestyramine)

• B. Ezetimibe

• C. Fibric acid (e.g., gemfibrozil)

• D. Fish oil supplement

• E. HMG-CoA reductase inhibitors (e.g., statins)

• F. Nicotinic acid

• G. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (e.g., alirocumab, evolocumab)

> The correct answer is E.

TEACHING POINT

# Lipid-Lowering Medications

Statins (HMG-CoA reductase inhibitors) are first-line therapy for most patients who require lipid-lowering therapy because they can:

• Stabilize existing plaques, reduce inflammation, and decrease the risk of plaque rupture and myocardial infarction

• Decrease CHD and all-cause mortality

• Decrease LDL by 18% to 55%

• Increase HDL by 5% to 15%

• Decrease triglycerides by 7% to 30%

Bile acid sequestrants, such as cholestyramine, have a more modest effect on lowering LDL and raising HDL. Usage has been limited by severe gastrointestinal distress. According to ACC/AHA 2018 guidelines, in patients with an LDL level of 190 or higher who do not achieve at least a 50% reduction in LDL on maximally-tolerated statin and ezetimibe therapy, a bile acid sequestrant may be considered.

Ezetimibe inhibits absorption of cholesterol at the intestinal brush border and increases cholesterol clearance. According to ACC/AHA 2018 guidelines, in patients with an LDL level of 190 or higher who do not achieve at least a 50% reduction in LDL on maximally-tolerated statin therapy or individuals with clinical ASCVD who have an LDL level of 70 or higher after maximally tolerated statin therapy, ezetimibe therapy is reasonable. Ezetimibe has been shown to reduce LDL cholesterol levels and lower rates of cardiovascular outcomes although it has not been shown to impact cardiovascular- or all-cause mortality.

Fibric acid derivatives are first-line therapy for reducing triglycerides but have only a modest effect on reducing LDL. They can increase HDL-cholesterol by 10% to 20%.

Fish oil supplements have been shown to decrease triglycerides by 25% to 30%. They also increase HDL cholesterol slightly. Small studies suggest some decrease in progression of atherosclerosis in patients taking high doses of fish oil.

Nicotinic acid (niacin, or vitamin B3) has a more modest effect on LDL. However, it is the most effective agent to increase HDL (by 15% to 30%) and can also decrease triglycerides (by 20% to 50%). Randomized controlled trials do not support use of nicotinic acid as add-on therapy to statin therapy for the purposes of lowering cholesterol.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are newer antibody agents that block the PCSK9 liver enzyme, which typically acts by binding to the LDL receptor on the surface of hepatocytes, leading to degradation and higher plasma LDL-cholesterol levels. PCSK9 inhibitors have been shown to lower LDL cholesterol levels and their use is associated with significantly lower risk of myocardial infarction and stroke. They may be used in combination with statin agents, typically after maximizing both statin and ezetimibe therapy. Notably, these medications are given by subcutaneous injection, may be cost-prohibitive for some patients and long-term side effects remain uncertain at this time.

# DISCUSSING STATINS

##### THERAPEUTICS

Dr. Simon goes on to explain, “Statins are one of the drugs I prescribe the most.”

TEACHING POINT

# Statins

Effectiveness

Statins are very effective at lowering LDL and total cholesterol. There is good data on use in primary and secondary prevention of CHD.

Dosage

ACC/AHA guidelines recommend selecting a statin dose based on the patient’s ASCVD risk factors, rather than adjusting the dose to target a specific LDL cholesterol goal, as recommended in earlier guidelines.

Dosages that lower LDL cholesterol by 30–50% are considered moderate-intensity statins; dosages that lower LDL cholesterol by > 50% are considered high-intensity statins.

High-intensity therapy is recommended for:

• Patients ≤ 75 years of age with clinical ASCVD and no safety concerns

• Patients with LDL cholesterol > 190 mg/dL

• People with diabetes who are 40–75 years of age with multiple ASCVD risk factors

Moderate intensity therapy is recommended for:

• Patients > 75 years of age with clinical ASCVD*

• People with diabetes who are 40–75 years of age (no ASCVD risk calculation necessary but can consider if LDL level 70–189 mg/dL to determine indication for high-intensity statin)

• Patients for whom high-dose therapy would be recommended but who are not candidates for high-intensity statins due to statin-associated side effects or other contraindications

*Note: For these patients, high-intensity statin may also be considered but patient preferences and frailty, drug-drug interactions and adverse effects should all be taken into account.

Side effects

• Hepatic dysfunction

Liver aminotransferases should be measured before starting a statin, but there is no recommendation for routine monitoring of hepatic function in asymptomatic patients without a history of liver disease after treatment is started. Hepatic function tests should be measured in patients who develop symptoms of hepatotoxicity while on statin therapy. In patients with increased ASCVD risk with chronic, stable liver disease, it is reasonable to use statins after obtaining baseline measurements and monitoring thereafter.

Myopathy

CK should be measured before starting statin therapy in patients who are at increased risk for myopathy, and in any patient who develops symptoms of myopathy or objective muscle weakness during statin treatment.

Contraindications

Statins are contraindicated during pregnancy.

# NONPHARMACOLOGIC THERAPY

##### THERAPEUTICS

“Even though we’re not starting medication at this point,” Dr. Simon explains, “I don’t want you or Mr. James to think that his borderline high LDL cholesterol is unimportant. We’ll continue to check it every three to five years, and at some point he may benefit from medication. In the meantime, what can he do to try to improve his cholesterol?”

# Question

Which four nonpharmacologic interventions lower LDL cholesterol? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• A. Alcohol cessation

• B. Increased dietary fiber

• C. Increased physical activity

• D. Reduction of saturated fat in diet

• E. Weight loss

> The correct answers are B, C, D, E.

TEACHING POINT

# Nonpharmacologic interventions to lower LDL

Lifestyle changes should be first-line therapy for all patients with dyslipidemias, whether or not medication is being prescribed.

ACC/AHA recommends lifestyle modifications as a critical component in ASCVD risk reduction.

Diet

 Category Recommendation Evidence Quality All adults Mediterranean-style diet (the DASH dietary pattern achieves this). This diet is rich in: Vegetables Fresh fruits Whole grains Lean meats: poultry, pork, fish Legumes: e.g., lentils Non-tropical vegetable oils: e.g., olive oil Tree nuts: pecans, cashews, etc. (not peanuts) And low in: Sugar-sweetened beverages Sweets Red or processed meats A (strong) Those needing LDL lowering (recommendations should be made irrespective of whether the patient has an indication for a statin) Reduce percent of calories from saturated fat. Saturated fats come from: Animal fats (meat and dairy) Some vegetable oils (particularly coconut and palm oils) Reduce percent of calories from trans fat. These come from: Partially hydrogenated oils Oils used for deep frying Vegetable shortenings Many prepackaged baked goods and chips B (moderate) B (moderate) Those needing BP lowering (unlike with cholesterol management, if a patient can lower his BP with diet, he may avoid the need for medications) Reduce sodium intake The optimal goal for patients is to limit sodium intake to 1,500 mg/day At minimum, patients should aim for a 1000 mg/d reduction in sodium intake B (moderate)

Exercise

On the basis of moderate quality evidence, all adults are encouraged to engage in at least 150 minutes per week of accumulated moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity to reduce ASCVD risk.

# References

Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation. 2019 Sep 10;140(11):e647-e648] [published correction appears in Circulation. 2020 Jan 28;141(4):e59] [published correction appears in Circulation. 2020 Apr 21;141(16):e773]. Circulation. 2019;140(11):e563-e595.

Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation. 2019 Jun 18;139(25):e1182-e1186]. Circulation. 2019;139(25):e1082-e1143.

Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25 Pt B):2889-934.

# DISCUSSING DIET

##### CARE DISCUSSION

Once you and Dr. Simon have finished discussing dyslipidemias and lipid-lowering medications, you both go in to see Mr. James. You tell him that his blood sugar is normal, but his cholesterol is a little high.

You decide to give Mr. James more concrete dietary advice and ask him to describe everything he ate the day before. You note he has several soft drinks a day. You also provide him with resources to help with beginning to cook at home.

You go online and calculate his caloric intake with Mr. James and discover he consumed about 2800 calories yesterday in fast food and soft drinks.

“I don’t really know much about nutrition, but one of my friends told me about a free app for my smartphone that he uses to track calories. I can try that,” says Mr. James. “But how many calories should I be eating?”

TEACHING POINT

# Estimating Daily Caloric Requirement

The estimated total caloric intake needed to maintain current weight = basal metabolic rate + additional calories for activity.

There are resources that can help patients estimate their daily caloric needs, including these guidelines from the U.S. Department of Health and Human Services.

# COUNSELING ON WEIGHT LOSS

##### CARE DISCUSSION

You estimate that Mr. James’ daily caloric requirement to maintain his current body weight is about 2500 calories. However, you don’t want Mr. James to maintain his current body weight, you want him to lose weight. You tell Mr. James that weight loss will require him to burn more calories than he eats, either by reducing calories, increasing physical activity, or both.

TEACHING POINT

# Setting Realistic Weight loss Goals

Achieving ideal body weight is an unrealistic goal for many patients with obesity.

• Reasonable long-term goal: A modest 5% to 10% reduction in body weight can produce significant benefits in health outcomes.

• Reasonable short-term goal: Losing half a pound to a pound a week.

# Question

What caloric deficit is needed to lose one pound of body weight per week? Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

• A. 1,500

• B. 2,000

• C. 2,500

• D. 3,000

• E. 3,500

• F. 4,000

• G. 4,500

> The correct answer is E.

TEACHING POINT

# Caloric Deficit for Weight Loss

A patient needs to have approximately a 3,500 calorie deficit to lose 1 pound of weight per week.

Patients who believe they are following these recommendations for caloric intake may not lose this much weight for several reasons:

1. Tendency to underestimate actual caloric intake.

Patients should be encouraged to read food packaging labels and, if necessary, weigh or measure their food to determine accurate portion sizes and caloric content.

2. These numbers are only estimates of the actual caloric requirement.

Although there is an activity factor in the calculation, variations in day-to-day physical activity and individual metabolic rates can result in substantial variation in energy requirements.

3. The “plateau” phenomenon.

As patients lose weight, their caloric requirements decrease and they eventually reach a point where they stop losing weight, even if they maintain the caloric intake previously producing weight loss.

Regardless of the cause, if patients are unable to lose weight or continue to gain weight, they need to further restrict calories or increase physical activity.

# DIETARY COUNSELING

##### CARE DISCUSSION

“I’ve given you a lot of information to keep up with,” you acknowledge, “but using a website or app to help you track things is a great idea.

TEACHING POINT

# Approach to Dietary Counseling

A variety of diets have been shown to produce modest weight loss and adherence to any diet is a core component of weight loss success. Which diet to recommend may vary by the specific patient, their preferences and their unique comorbidities.

Encourage patients attempting to lose weight to:

1. Set a concrete goal

2. Read food labels and be aware of portion sizes

3. Consider self-monitoring (e.g., using food diaries, activity records)

4. Adopt a healthy, long-term approach to eating

Use resources like the USDA website, www.myplate.gov, which allows users to enter their age, weight, height, gender, and level of physical activity as well as receive customized recommendations for the quantities of each food group (grains, vegetables, fruits, meat and beans, and milk) they should be eating each day.

If your patient is unable to lose weight: Consider referral to a nutritionist. Be aware that dieticians are not always covered by insurance.

# COUNSELING ON EXERCISE

##### CARE DISCUSSION

In addition to diet, you also need to talk to Mr. James about exercise. He confides that he is concerned he will hurt himself if he tries to exercise. You reassure him that he doesn’t have to exercise vigorously and risk injury to reap the health benefits. “Just start out slowly and build up gradually,” you advise him. You go on to explain the recommendations for exercising.

TEACHING POINT

# Guidelines for Exercise Prescription

Strategies for patient motivation and behavior change

1. Determine your patient’s motivation for physical activity.

2. Explore ways to incorporate more physical activity into your patient’s daily activities. (For example, taking the stairs instead of the elevator, parking the car farther away from the door in order to walk farther—this can be a less intimidating way of introducing exercise to sedentary patients.)

3. Develop a detailed plan. Patients are more likely to adhere to recommendations about exercise if they have a specific plan.

4. Help your patient identify possible barriers to the exercise plan. Together, devise ways to circumvent these barriers.

Recommendations for frequency, duration, and intensity of exercise

Frequency and Duration

• All adults are encouraged to engage in at least 150 minutes per week of accumulated moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity to reduce ASCVD risk. However, if someone is not currently exercising, starting with intermediate goals and building up to 150 minutes a week overtime is reasonable.

Intensity

Moderate-intensity exertion

• Should be able to talk well enough to carry on a conversation comfortably, but should be too breathless to sing.

• Target heart rate for moderate exertion is 50-70% of the maximum heart rate. Calculated as 220 minus age.

Resource for patients

The Centers for Disease Control and Prevention (CDC) web site “Physical Activity for Everyone” includes information to help patients understand the benefits of physical activity, suggestions for overcoming barriers to physical activity, and stage-appropriate suggestions for moving toward more physical activity. The CDC web site “Physical Activity Recommendations for Different Age Groups” provides specific age-based activity goals.

# References

Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Applications to addictive behaviors. Am Psychol. 1992;47(9):1102-14.

# OBESITY TREATMENT

##### THERAPEUTICS

Mr. James is starting to look a bit concerned. “That’s a lot of information, and it sounds like it’s going to be hard work. Couldn’t I just take a pill or get my stomach stapled or something?”

# Question

Other than dietary modifications and exercise, which therapies are approved for management of obesity? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• A. Bariatric surgery

• B. Insulin injection

• C. Laxative usage

• D. Liposuction

• E. Pharmacologic weight loss therapy

> The correct answers are A, E. See the Teaching Point below.

Insulin (B) causes weight gain, not weight loss.

Laxative use (C) is ineffective for long-term weight loss and can cause electrolyte disturbances.

Liposuction (D) is cosmetic surgery and is not designed for permanent weight loss.

TEACHING POINT

# Management of Obesity

Pharmacologic therapy and bariatric surgery are both approved for management of obesity. However, it is important to emphasize to patients that these are adjuncts to dietary changes and physical activity, not replacements for them.

Pharmacotherapy

Indications: All weight loss medications approved by the FDA are indicated for patients with BMI > 30; most are also indicated for patients with BMI > 27 with at least one weight-related comorbidity, such as hypertension or diabetes. Individuals must have not met weight loss goals (at least 5% of total body weight) over three to six months using a comprehensive lifestyle intervention approach.

 Medication Mechanism Side Effects Notes Liraglutide Semaglutide GLP-1 agonist Nausea Vomiting Diarrhea Constipation Injection site reactions Hypoglycemia in patients with DM2 Contraindicated in pregnancy or patients with personal or family history of MEN2A or 2B. Not recommended in severe renal or hepatic impairment. Phentermine Diethylpropion Phendimetrazine Benzphetamine Noradrenergic sympathomimetic; appetite suppressant Tachycardia Hypertension Insomnia Anxiety Constipation Indicated for short-term (< 12 weeks) use only, controlled substances Phentermine-topiramate (Qsymia) Acts via multiple pathways to suppress appetite Paresthesias Dry mouth Insomnia Cognitive changes Tachycardia Constipation Anxiety Contraindicated in pregnancy, hyperthyroidism, glaucoma, patients taking MAO inhibitors Orlistat Pancreatic lipase inhibitor, which decreases fat absorption Gastrointestinal discomfort Fecal incontinence Malabsorption of fat-soluble vitamins Available without a prescription Contraindicated in pregnancy Naltrexone-bupropion (Contrave) Naltrexone is an opioid antagonist, and bupropion is a relatively weak inhibitor of the neuronal reuptake of dopamine and norepinephrine. Headache Sleep disorder Constipation Nausea Vomiting Dizziness Transient tachycardia or hypertension Contraindicated in patients with uncontrolled hypertension, seizure disorder, eating disorder, chronic opioid use, pregnancy or breastfeeding

Studies have shown that—when combined with lifestyle modifications—in general, these medications result in an additional weight loss of 3% to 9% compared to placebo, though semaglutide may have a greater benefit. In a study of high dose semaglutide, 2.4 mg/wk, the mean weight loss at 68 weeks was 14.9%.

Bariatric surgery

Indications: Patients with BMI > 40 or BMI ≥ 35 with associated weight-related comorbidity who have not succeeded in losing weight with other treatment methods.

Procedures include:

• Gastric bypass (Roux-en-Y): partitioning of the stomach with attachment of the proximal stomach to the jejunum with resultant malabsorptive and volume-restrictive effects

• Sleeve gastrectomy: partial gastrectomy in which a tubular stomach is created with volume-restrictive effects

• Biliopancreatic diversion with duodenal switch: anastomotic surgery with resultant malabsorptive and volume-restrictive effects

# References

Gloy VL, Briel M, Bhatt DL, et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:f5934. Published 2013 Oct 22.

Wilding JPH, Batterham RL, Calanna S, et al. Once-Weekly Semaglutide in Adults with Overweight or Obesity. N Engl J Med. 2021;384(11):989.

Yanovski SZ, Yanovski JA. Long-term drug treatment for obesity: a systematic and clinical review. JAMA. 2014;311(1):74-86.

# PLANNING FOR FOLLOW-UP

##### CARE DISCUSSION

Mr. James is delighted when you tell him that he’s “not fat enough” for bariatric surgery, and somewhat alarmed by the potential side effects of the different medications you describe to him. He decides that he would rather give diet and exercise a try.

Mr. James and Dr. Simon make a plan for follow-up, then Mr. James thanks you both for your help and heads out the door.

##### FINISH CASE

Well done! You have completed the case. Click to download the case summary.

# May 10, 2022

• This case was reviewed and updated by the Aquifer Internal Medicine Course Board.

# LEARNING OBJECTIVES

##### LEARNING OBJECTIVES

The student should be able to:

• Discuss health implications of obesity.

• Assess risk factors for obesity.

• Understand how to assess for obesity and its implications.

• Describe possible physical findings of hypercholesterolemia.

• List etiologies of primary and secondary dyslipidemias.

• Describe screening recommendations for dyslipidemias in adults.

• Outline basic management of common dyslipidemias, including therapeutic lifestyle changes.

• Identify pharmacologic and surgical approaches to obesity management.

# Question

A 67-year-old male comes to the clinic for a health maintenance visit. His past medical history is significant for atrial fibrillation, severe chronic obstructive pulmonary disease (COPD), osteoporosis, psoriasis, chronic allergic rhinitis, and benign prostatic hypertrophy. Vital signs show his temperature is 36.8 C (98.2 F), pulse is 76 beats/minute, respiratory rate is 12 breaths/minute, and blood pressure is 118/70 mmHg. His weight is 129.2 kg (285 lbs) and his body mass index (BMI) is 41. Which of his co-morbidities is most likely to be associated with his BMI?

• A. Atrial fibrillation
• B. Benign prostatic hypertrophy
• C. Chronic allergic rhinitis
• D. Osteoporosis
• E. Psoriasis

# Question

A 52-year-old female comes to the clinic to discuss weight loss. Her medical history is significant for obesity (body mass index (BMI) 41), hypertension, hyperlipidemia, and obstructive sleep apnea. She knows that losing weight will help her hypertension and hyperlipidemia, but she doesn’t feel like these things bother her. Her only other concern is fatigue; she doesn’t use her continuous positive airway pressure (CPAP) machine, because she doesn’t like the mask. What additional information can you provide her to help motivate her weight loss?

• A. Her obstructive sleep apnea may improve with weight loss.
• B. Her risk of cardiovascular disease is similar to that of a female with a normal BMI.
• C. Obesity is mainly a cosmetic issue.
• D. Surgery should be considered before diet and exercise.

# Question

A 42-year-old female with no significant past medical history presents to establish care with her primary care physician. On review, she notes a weight gain of 14 kg (30 lbs) over the last three years. She attributes this mostly to her sedentary lifestyle, snacking, and difficulty with portion control. She works as a receptionist for a local physician’s office and spends most of her day sitting. She reports no constipation, low energy, cold intolerance, muscle weakness, depressed mood, easy bruisability, or other skin changes. On physical exam, vital signs reveal temperature is 36.8 C (98.2 F), pulse is 82 beats/minute, respiratory rate is 12 breaths/minute, blood pressure is 130/82 mmHg, weight is 81.6 kg (180 lbs), and height is 163 cm (64 in). The remainder of her physical exam is normal. Which of the following laboratory tests is most appropriate for the evaluation of this patient?

• A. 24-hour urine catecholamine levels
• B. 24-hour urine cortisol level
• C. Basic metabolic profile
• D. Lipid profile
• E. Thyroid stimulating hormone (TSH)

# Question

A 44-year-old male presents for evaluation of an eyelid lesion. He noticed the lesion about one year ago. There is no associated itching, discharge, or other bothersome symptoms. Which of the following is the next best step in the management of the eyelid lesion?

• A. Low potency topical corticosteroid
• B. Measurement of serum cholesterol levels
• C. Measurement of serum uric acid levels
• D. No further management
• E. Skin biopsy

# Question

A 68-year-old female presents with a medical history significant for obesity, type II diabetes, hypothyroidism, hypertension, and recently diagnosed hyperlipidemia. Her most-recent lipoprotein (LDL), three months ago, was 197 mg/dL. At that time, atorvastatin was initiated. Other medications include metformin, insulin glargine, amlodipine, hydrochlorothiazide, and levothyroxine. Which of the following may be contributing to her elevated LDL?

• A. Amlodipine
• B. Hydrochlorothiazide
• C. Insulin glargine
• D. Levothyroxine
• E. Metformin

Thank you for completing Internal Medicine 16: 45-year-old male who is overweight.