January 2014 JMSMA.indd

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is lifesaving.21. Hyperosmolar hyperglycemic state (HHS), myxedema coma and acute adrenal insufficiency should be suspected in the appropriate clinical ...
• TOP TEN FACTS YOU NEED TO KNOW • About Obese Adults Admitted to Hospital Dominique J. Pepper, MD; Michael Brewer, DO; Christian A. Koch, MD

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NTRODUCTION

The CDC defines obesity as a BMI > 30 kg/m2 (body mass index [weight in kilograms divided by height in meters squared]).1 This definition is useful for obesity screening but does not necessarily separate ‘metabolically healthy’ obese individuals from those with high cardiovascular risk.2,3 In 2008, the cost of health care due to obesity in the United States of America (USA) exceeded $147bn.1 In 2011 Mississippi had the highest prevalence of self-reported obesity among adults (34.9%) in the USA.1 Obese adults admitted to the hospital pose several unique diagnostic and therapeutic challenges. The purpose of this article is to alert clinicians to these challenges. 1. Cardiac: Obesity increases the risk of systemic hypertension, pulmonary hypertension, autonomic dysfunction, and a prolonged QTc interval,4-7 all of which may complicate hospitalization and outcomes following surgery. A longer duration of abdominal obesity increases subclinical coronary heart disease and its progression through midlife.8 Paradoxically, mortality following acute myocardial infarction decreases with increasing BMI. The increased age of those with a normal BMI drives this paradox.9,10 Obese adults in acute heart failure often have normal BNP levels.11 2. Respiratory: Oxygen and non-invasive ventilation (continuous positive airway pressure [CPAP] or bilevel PAP) improve chronic daytime hypercapnia and hypoxia in adults with obesity hypoventilation syndrome. 12-14 In obese adults with postoperative atelectasis due to lung or abdominal surgery, CPAP reduces the risk of pneumonia and intubation.15 In intubated adults, obesity does not increase mortality but does prolong time on mechanical ventilation and duration in the ICU.16 AUTHOR INFORMATION: PGY-3 Resident, Department of Medicine, University of Mississippi School of Medicine, Jackson (Dr. Pepper); PGY-2 Resident, Department of Medicine, University of Mississippi Medical Center, Jackson (Dr. Brewer); Professor, Division of Endocrinology, Director, Endocrine Tumor Program, Cancer Institute, University of Mississippi Medical Center, Jackson (Dr. Koch). CORRESPONDING AUTHOR: Dominique J Pepper, MD, PGY-3 Resident, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216 Telephone: (601)9845601, ([email protected]).

3. Gastrointestinal: Central adiposity correlates with an increased risk of gastroesophageal reflux disease, cholecystitis, and non-alcoholic fatty liver disease (NAFLD).17,18 NAFLD affects nearly one-third of Americans,19 and increases the risk of cirrhosis, liver-related death, and drug toxicity. Cytochrome p450 enzymes, located primarily in the liver, metabolize almost two thirds of the 200 most commonly prescribed drugs. 20 4. Endocrine: Appropriate endocrine screening and early recognition of endocrine emergencies in obese adults is lifesaving.21 Hyperosmolar hyperglycemic state (HHS), myxedema coma and acute adrenal insufficiency should be suspected in the appropriate clinical setting. The American Diabetes Association defines HHS as blood glucose >600 mg/ dl, pH >7.30, bicarbonate >15 mmol/l, and serum osmolality >320.21 Clinicians should suspect HHS in middle-aged, obese patients with type 2 diabetes presenting with polyuria, polydipsia and weight loss. Myxedema coma should be considered in unresponsive obese adults with a history of hypothyroidism, previous thyroidectomy or previous radioactive iodine treatment.22 Acute adrenal insufficiency should be suspected in obese adults on steroid replacement with failure to increase the steroid dose after experiencing an acute stress episode.23 Overt signs and symptoms of Cushing syndrome (central obesity, hypertension and hypokalemia) and polycystic ovarian syndrome (central obesity, acne and hirsutism) should prompt appropriate testing.24,25 5. Rheumatologic: Obesity increases the mechanical load on weight-bearing joints, predisposing to osteoarthritis.26 Critically ill obese adults have impaired mobilityduring inpatient admission, which may lead to muscle de-conditioning. Timely initiation of physical therapy during recovery may prevent unnecessary falls and their complications. Pressure care with the aid of bariatric beds may reduce skin breakdown. 6. Oncology: Obese adults have increased rates and later stages of cancer, particularly colon cancer and estrogen sensitive cancers (endometrial and breast).27,28 Clinicians need to perform age-appropriate cancer screening in a timely manner among obese adults. 7. Radiology: There is often a lack of suitably sized stretchers and wheelchairs to transport obese patients to radiology departments. Lipomatosis, which involves the gut and the mediastinum in obese adults, poses several challenges in diagnostic imaging quality, including image acquisition, JANUARY

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and image interpretation.29,30 The weight limit of the imaging table or the aperture diameter of the MRI scanner may preclude diagnostic imaging causing diagnostic delays in life-threatening illnesses. Acquired images may be suboptimal because of soft-tissue artifact, or the need to alter the timing, duration, or protocol of contrast administration.29,30

9.

Sarno G, Räber L, Onuma Y et al. Impact of body mass index on the five-year outcome of patients having percutaneous coronary interventions with drug-eluting stents. Am J Cardiol. 2011;108(2):195-201.

10.

Uretsky S, Messerli FH, Bangalore S et al. Obesity paradox in patients with hypertension and coronary artery disease. Am J Med. 2007;120(10):86370.

11.

Noveanu M, Breidthardt T, Cayir S et al. B-type natriuretic peptideguided management and outcome in patients with obesity and dyspnea-results from the BASEL study. Am Heart J. 2009;158(3): 488-95

8. Pregnancy: Extremely obese adult women are more likely to have gestational hypertension, gestational diabetes, shoulder dystocia, cesarean section, birth weight ≥ 4000 gm, neonatal metabolic abnormality, neonatal ICU admission and still-birth.31

12.

Mokhlesi B, Tulaimat A. Recent advances in obesity hypoventilation syndrome. Chest. 2007;132(4): 1322-1336

13.

Tamanna S, Ullah MI. Top 10 facts you should know: About how to improve CPAP compliance for the treatment of obstructive sleep apnea. J Miss State Med Assoc. 2012;53(7):220-1

14.

Tamanna S, Ullah MI. About obstructive sleep apnea. J Miss State Med Assoc. 2011;52(1):12-3

9. DVT prophylaxis:The risk of deep vein thrombosis increases in immobile obese adults admitted to the hospital, and appropriate prophylaxis is necessary. In patients with hypercortisolemia, the risk of DVT increases further.32 The optimal prophylactic dose for deep venous thrombosis in obese adults is not known.

15.

Pessoa KC, Araújo GF, Pinheiro AN et al. Noninvasive ventilation in the immediate postoperative of gastrojejunal derivation with Roux-en-Y gastric bypass. Rev Bras Fisioter. 2010;14(4):290-5.

16.

Martino JL, Stapleton RD, Wang M et al. Extreme obesity and outcomes in critically ill patients. Chest. 2011;140(5):1198-206

17.

Beddy P, Howard J, McMahon C et al. Association of visceral adiposity with oesophageal and junctional adenocarcinomas. Br J Surg. 2010;97(7):1028-34.

10. Pharmacology: Pharmacokinetic data in obese patients do not exist for most drugs. In situations where such information is available, clinicians should design treatment regimens that account for any significant differences in the drug clearance and the volume of distribution in the obese (based on the lipophilic and hydrophilic tendencies of the drug).33 Careful discussions with the hospital pharmacist to decide whether to dose obese adults on ideal, actual or adjusted body weights are necessary.

18.

Ahrens W, Timmer A, Vyberg M et al. Risk factors for extrahepatic biliary tract carcinoma in men: medical conditions and lifestyle: results from a European multicentre case-control study. Eur J Gastroenterol Hepatol. 2007;19(8):623-30.

19.

Wieckowska A, Feldstein AE. Diagnosis of nonalcoholic fatty liver disease: invasive versus noninvasive. Semin Liver Dis. 2008;28(4):38695.

20.

Williams JA, Hyland R, Jones BC, Smith DA, Hurst S, Goosen TC, Peterkin V, Koup JR, Ball SE. Drug-drug interactions for UDPglucuronosyltransferase substrates: a pharmacokinetic explanation for typically observed low exposure (AUCi/AUC) ratios. Drug Metab Dispos. 2004;32(11):1201-8

21.

Kitabchi AE, Umpierrez GE, Murphy MB, Kreisberg RA. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29(12):2739-48.

CONCLUSION

22.

Garber JR, Cobin RH, Gharib H et al. Clinical practice guidelines for hypothyroidism in adults. Endocr Pract. 2012;18(6):988-1028

23.

Seetho IW, Wilding JP. How to approach endocrine assessment in severe obesity? Clin Endocrinol 2013;79(2):163-7

24.

Koch CA. Endocrine hypertension: what is new? Rev Port Endocrinol Diabetes Metab. 2012;7(2):52-61

25.

Nieman LK, Biller BM, Findling JW. The diagnosis of Cushing’s syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2008;93(5):1526-1540

REFERENCES

26.

Conde J, Scotece M, López V, Gómez R, Lago F, et al. Adipokines: novel players in rheumatic diseases. Discov Med. 2013;15(81):73-83

1.

CDC 2013 Adult Obesity Facts http://www.cdc.gov/obesity/data/adult. html [Accessed November 27, 2013]

27.

2.

Ahima RS, Lazar MA. Physiology. The health risk of obesity--better metrics imperative. Science. 2013 Aug 23;341(6148):856-8

Reeves GK, Pirie K, Beral V et al. Cancer incidence and mortality in relation to body mass index in the Million Women Study: cohort study. BMJ. 2007;335(7630):1134.

28.

3.

Melcescu E, Griswold M, Xiang L, Belk S, Montgomery D, Bray M, Del Ben KS, Uwaifo GI, Marshall GD, Koch CA. Prevalence and cardiometabolic associations of the glucocorticoid receptor gene polymorphisms N363S and BclI in obese and non-obese black and white Mississippians. Hormones (Athens). 2012 Apr-Jun;11(2):166-77

Tao W, Lagergren J. Clinical management of obese patients with cancer. Nat Rev Clin Oncol. 2013 Jul 16. doi: 10.1038/nrclinonc.2013.120. [Epub ahead of print]

29.

Ghanem MA, Kazim NA, Elgazzar AH. Impact of obesity on nuclear medicine imaging. J Nucl Med Technol. 2011;39(1):40-50.

30.

Vannier MW. CT clinical perspective: challenges and the impact of future technology developments. Conf Proc IEEE Eng Med Biol Soc. 2009;1909-12

31.

Crane JM, Murphy P, Burrage L et al. Maternal and perinatal outcomes of extreme obesity in pregnancy. J Obstet Gynaecol Can. 2013;35(7):606-11

32.

Stuijver DJ, van Zaane B, Feelders RA et al. Incidence of venous thromboembolism in patients with Cushing’s syndrome: a multicenter cohort study. J Clin Endocrinol Metab. 2011;96(11):3525-32

33.

Hanley MJ, Abernethy DR, Greenblatt DJ. Effect of obesity on the pharmacokinetics of drugs in humans. Clin Pharmacokinet. 2010;49(2):71-87

34.

Pickkers P, de Keizer N, Dusseljee J et al. Body mass index is associated with hospital mortality in critically ill patients: an observational cohort study. Crit Care Med. 2013;41(8):1878-83.

All adults admitted to the hospital should be screened for obesity, which poses significant inpatient challenges.34 Early identification and timely treatment of obesity-related illnesses may prevent complications and reduce the high cost of health care.

4.

Seip RL, Mair K, Cole TG et al. Induction of human skeletal muscle lipoprotein lipase gene expression by short-term exercise is transient. Am J Physiol. 1997;272:E255-61.

5.

Vinik AI, Maser RE, Ziegler D. Autonomic imbalance: prophet of doom or scope for hope? Diabet Med. 2011;28(6):643-51.

6.

Dimkpa U, Oji JO. Relationship of body mass index with haemodynamic variables and abnormalities in young adults. J Hum Hypertens. 2010;24(4):230-6.

7.

Baba R, Koketsu M, Nagashima M et al. Adolescent obesity adversely affects blood pressure and resting heart rate. Circ J. 2007;71(5):722-6.

8.

Reis JP, Loria CM, Lewis CE et al. Association between duration of overall and abdominal obesity beginning in young adulthood and coronary artery calcification in middle age. JAMA. 2013;310(3):280-8.

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