Harvey's Garden

Obesity and metabolic syndrome

Properties2
tags—
aliasesObesity, Obesity Hypoventilation Syndrome

2 min read

Epidemiology

Etiology

Pathophysiology

Clinical features

  • Metabolic: Type 2 DM (insulin resistance), Dyslipidemia (↑ TG, ↓ HDL), Metabolic Syndrome.
  • Cardiovascular: HTN, CAD, CHF, DVT/PE.
  • Respiratory:
    • Obstructive Sleep Apnea (OSA): Daytime somnolence, snoring.
    • Obesity Hypoventilation Syndrome (Pickwickian Syndrome): BMI ≥ 30 + daytime hypercapnia (↑ PaCO2) + hypoxemia due to restricted chest wall mechanics. c
  • Gastrointestinal: GERD, NAFLD/NASH (steatosis), Cholelithiasis (↑ cholesterol excretion).
  • Musculoskeletal: Osteoarthritis (esp. knees/hips), Slipped Capital Femoral Epiphysis (SCFE) in adolescents.
  • Reproductive/Endocrine: PCOS (peripheral conversion of androgens to estrone in adipose tissue), infertility.
  • Oncology: Increased risk of Endometrial (due to unopposed estrogen), Breast (postmenopausal), Colon, Renal, and Esophageal (adenocarcinoma) cancers.

Diagnostics

Treatment

  1. First-Line (Lifestyle & Behavioral Modifications):
    • USPSTF recommends referring all adults with BMI ≥ 30 to intensive, multicomponent behavioral interventions (dietary changes, physical activity, CBT).
    • Exercise goal: Target ≥150 minutes/week of moderate-intensity aerobic exercise.
    • Weight-loss goals: initial weight loss goal of 5-10% of baseline weight within 6 months c
  2. Second-Line (Pharmacotherapy):
    • Indications: BMI ≥ 30 OR BMI ≥ 27 with ≥1 weight-related comorbidity (e.g., HTN, DM2, dyslipidemia, OSA) in patients who have failed lifestyle modifications alone.
    • GLP-1 receptor agonists (e.g., semaglutide, liraglutide) / Dual GIP/GLP-1 receptor agonists (e.g., tirzepatide): Highly effective; preferred first-line in patients with concurrent DM2 or ASCVD. AE: Nausea, delayed gastric emptying, pancreatitis.
    • Orlistat (lipase inhibitor): Blocks fat absorption in GI tract. AE: Oily stools/steatorrhea, fecal urgency, flatulence, and malabsorption of fat-soluble vitamins (A, D, E, K).
    • Phentermine/Topiramate: Contraindicated in pregnancy (teratogenic, requires contraception/negative pregnancy test) and uncontrolled HTN.
    • Naltrexone/Bupropion: Contraindicated in patients with seizure disorders, eating disorders (bulimia, anorexia), or chronic opioid use.
  3. Third-Line / Definitive (Metabolic/Bariatric Surgery):
    • Indications: BMI ≥ 40 OR BMI ≥ 35 with serious obesity-related comorbidities (e.g., DM2, HTN, severe OSA, NAFLD/MASLD) in patients who have failed non-surgical weight loss interventions. c
    • Procedures:
      • Sleeve Gastrectomy (restrictive, most common): Avoid/not preferred in severe GERD as it can worsen reflux.
      • Roux-en-Y Gastric Bypass (RYGB) (restrictive & malabsorptive): Procedure of choice for patients with concurrent severe GERD or poorly controlled DM2.
  • Key Comorbidities
    • T2DM, HTN, OSA, NAFLD, osteoarthritis, ↑ cancer risk

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