THE VERY OVERWEIGHT PATIENT (BMI> 33)
CLIFF NOTES REFERENCE MANUAL and SMART SHEET for COMPLIANCE

presented by

"RECROSSING THE LINE"

Weary and frustrated, a bedridden patient in a nursing home in Millersville, Md. Pulmonary hypertension, sleep apnea, cardiac disease, hypoventilation syndrome, ALL spiraling toward an obvious fateful outcome.

CAUSES:
OBESITY-RELATED CONDITIONS BY FREQUENCY IN THE USA PAGE 3

"RE-CROSSING THE LINE"
SUGGESTED TESTING INCLUDES:

FOR EXERCISE CAPABILITY , EXERCISE AND DIET PRESCRIPTIONS-

The following causes of Obesity are diseases or medical conditions that affect more than 10 million people in the USA:

The following causes of Obesity are diseases or conditions that affect
 more than 1 million people in the USA:

Causes of Obesity that are less common The following causes of Obesity are diseases or conditions that affect more than 200,000 people, but less than 1 million people in the USA:

 (by class-with examples)

Byetta, our favorite weight-related type II medication is not insulin. It should be given AFTER oral diabetics have failed, but before beginning insulin (according AACE quidelines). Byetta is associated with WEIGHT LOSS as opposed to weight gain (managed care plans typically cover the increased cost). It uses a much smaller injectable needle, but, again, is NOT an insulin.

Insulin Preparations
Which insulin to choose is based on an patient's lifestyle, your medical preferences and experience, and the patient's blood sugar levels. Among the criteria considered in choosing insulin are:

Treatment Options High Cholesterol *Further comparisons and study is suggested, however the following is a time-saving physician’s tool. It is taken from the ADA, AHA, and other creditable sources intended to be a quick, smart guide to a challenging science which is now America’s foremost clinical problem in morbidity and mortality.
Why be aggressive?
Decreasing total cholesterol by 10% can result in a 30% reduction in coronary heart disease incidence. For every 1% decrease in LDL (bad cholesterol levels), heart disease rates drop 2%. On the other hand, for every 1% decrease in HDL, there is a 2 to 3% increase in the risk of heart disease.
Patients with established cardiac disease and multiple risk factors (metabolic syndrome, diabetes, or smoking and COMPLIANCE ISSUES) are sometimes given more intense lifestyle changes. Diet and exercise are basic interventions, Healthier Choices’ goal is to summarize medication choices

The decision to start a patient with dietary therapy or drug therapy is usually based on a patient's LDL cholesterol levels, presence of heart disease, and risk factors. Your doctor should calculate your "10-year risk" (also known as a Framingham Risks) for developing heart disease and use that risk estimation to decide if and when to start cholesterol-lowering therapy either through dietary modifications or medications.
First think LDL not total cholesterol, though relative risks for each are reviewed above. Goal LDL level will also depend on the below listed factors. The following table illustrates guidelines

Discussion
For the initial drug treatment of hypercholesterolemia, HMG-CoA reductase inhibitors, "statins", are often used because of their effectiveness and low incidence of side effects. Currently, six statin drug classes are available. The choice of which to use will depend on how much cholesterol reduction is needed, your preferences (read below for help), and prescription insurance benefits

Cholesterol absorption inhibitors are a new class of cholesterol lowering agents and work together with statins to lower cholesterol. This class of drugs works to lower blood cholesterol levels by absorbing excess cholesterol (from foods) in the intestines and thus blocking cholesterol's entry into the bloodstream. In a study published by the Mayo Clinic in May 2005, it was found that the addition of Zetia (a cholesterol absorption inhibitor) to statin therapy may cause a further reduction in a patient’s cholesterol levels. It is thought that this reduction may be the result of the two drugs working together but at different areas of the cholesterol production pathway. In fact, one pharmacy manufacturer combined Zetia with a commonly used statin known as Zocor. This combination product is called Vytorin. However, as with any medications, there can be conflicting data. A study released this year (2008) said that objective control of plaque formation in the carotids was NOT seen with Zetia.
Beyond the basics: Cholesterol Subclasses –taken from Berkeley Heart Labs
We now know that cholesterol can be broken down beyond just LDL and HDL. Within both LDL and HDL, there exist particles that vary in their characteristics and therefore in their risk (in the case of LDL) and protective (in the case of HDL) factors for CAD. A much better assessment of CAD risk is achieved by enlarging the spectrum of testing to includeadditional disorders, such as a predominance of small particles within the LDL family (small LDL trait), and low levels of HDL2b, the most heart-protective type of HDL.

This more comprehensive approach can point to treatment that differs from traditional therapy and is more effective in slowing, halting, or reversing the progression of CAD.
LDL particles contribute to the harmful buildup of fat inside artery walls, a process called atherosclerosis. The LDL particles contribute to atherosclerosis partly by slipping through the spaces between the cells of the artery0-wall lining and unloading their cargoes of cholesterol inside the wall. LDL particles floating in the blood of the same person vary in size and small particles penetrate the artery wall with relative ease! Making matters worse, they are also more susceptible to oxidation, a chemical process that intensifies the atherosclerotic activity of LDL.
People with a predominance of small LDL particles have an increased risk of developing CAD and suffering a heart attack. The small LDL trait is found in 50% of men and postmenopausal women, and in 30% of pre-menopausal women with CAD. The small LDL trait is also present in 50% of their first-degree relatives, who may or may not have CAD symptoms.
HDL particles, on the other hand, inhibit atherosclerosis in part by carrying cholesterol out of the arterial wall and, the liver, via the circulation, which can dispose of it. The process is called reverse cholesterol transport. HDL2b is the most active of all the HDL particles in such transport. The more HDL2b you have the better

HMG-CoA Reductase is a chemical made in our bodies that helps the liver produce cholesterol. HMG CoA reductase inhibitors get in the way of that process, reducing the amount and frequency of cholesterol being produced. These medications cause the greatest reduction in cholesterol at the lowest doses and are used in many individuals at high risk of heart disease, or to help prevent those that have had a heart attack or stroke from having another one.
Drugs in the class
Atorvastatin (Lipitor) Lovastatin (Mevacor) Fluvastatin Extended-Release (Lescol XL) Fluvastatin (Lescol) Rosuvastatin (Crestor) Simvastatin (Zocor) Lovastatin Extended Release (Altocor, Altoprev) Pravastatin (Pravachol)
Cerivastatin - Withdrawn From The Market (Baycol - Withdrawn From The Market) Cholesterol Absorption Inhibitors
Drugs in this class work to lower blood cholesterol levels by absorbing excess cholesterol (from foods) in the intestines and thus blocking cholesterol entry into the bloodstream.
Drugs in the class
Ezetimibe (Zetia)- see carotid study results discussed above-this drug has a generally very low side-effect profile and continues to be prescribed by cardiologists and other physicians.
Page 9

Anti-lipidemic Agents How niacin lowers cholesterol levels is not well understood, but it seems to inhibit production of VLDL, and significantly lowers levels of triglycerides (primary indication) as well as LDLs. Niacin can also raise levels of HDL, the good cholesterol. Fibric acid derivatives affect the breakdown of body fats and reduce the amountof triglyceride manufactured by the liver. A very common side effect called ?flushing? (redness, burning,
and tingling of the skin) causes may individuals to stop using this medication.
Drugs in the class
Niacin (Niacor, Nicolar, Nicotinic Acid)
Bile Acid Resins Particles made up of bile and fat are reabsorbed by the small intestine, go into the blood, and travel directly to the liver where the bile is recycled. Bile acid resins absorb bile acid in the intestinal tract rather than let it be reabsorbed and reused by the body. This decrease in bile causes the liver to produce more bile. Since the liver uses cholesterol to produce bile, bile acid resins reduce cholesterol levels in the blood stream. Use of bile acid resins is a conservative approach to treating high cholesterol because the drug's action is limited to the intestinal tract. However, because they are known to be safe and have few side-effects, they are used to treat patients with moderately elevated LDL- cholesterol, in people who do not already have heart disease, and when drug therapy is necessary in young adult men and premenopausal women. They are also used in combination with other drugs (such as statins) to treat more severe forms of hypercholesterolemia.

Drugs in the class
Colesevelam (Welchol)
Colestipol (Colestid)
Cholestyramine Powder for Suspension (Prevalite, Questran, Questran Light)
Combination HMG-CoA Reductase and Cholesterol Absorption Inhibitors
This class combines the most potent cholesterol reducers (HMG-CoA reductase inhibitors statins) with another cholesterol lowering medication (Cholesterol Absorption Inhibitors) in one tablet to give those who take it that extra decrease in cholesterol they may not be able to achieve with one of the medications alone.
HMG-CoA reductase is a chemical made in our bodies that helps the liver produce cholesterol. HMG-CoA reductase inhibitors get in the way of that process, reducing the amount and frequency of cholesterol being produced.Cholesterol Absorption Inhibitors block cholesterol found in food from being absorbed into the blood stream from the intestinesThe combination works by blocking cholesterol production by the body and well as blocking absorption of cholesterol from the food we eat.
Drugs in the class
Ezetimibe and Simvastatin (Vytorin)
Treatment Options Elevated Triglyceride Levels
Fibric acid derivative or niacin may be most effective. Both medications work by decreasing the liver's production of triglycerides.
Additionally, fibric acid derivatives (or "fibrates") such as gemfibrozil also increase HDL-C production.Clofibrate (No Longer Available) (Atromid-S (No Longer Available))
Fenofibrate (Micronized) Capsules (Antara, Lofibra)
Gemfibrozil (Lopid)
Fenofibrate Tablets (Tricor, Triglide)

Here’s a "rough" sequence of diabetic, lipid, and blood pressure medications in order of

Cost and Significant Side Effects

The following lists are from pharmacists, internists, and endocrinologists and do not favor any manufacturers and are NOT, in total, the opinions from the ADA, AMA ,AHA or official group-since they aren’t "allowed" to do it.

Nonetheless, it is very informative, helpful, and we have made it as objective as possible (though a standard medical disclaimer makes final decisions the primary care provider’s responsibility).

THE LISTS ARE ORGANIZED AS FOLLOWS AND CAN BE DOWNLOADED AT WWW.SLIMMERSUCCESS.COM/SMARTCOMPLIANCE

The questionnaire first educates the patient as to the seriousness of uncontrolled diabetes , HTN, or hypercholesterolemia, before they begin answering their attitude results. It is a teaching tool for your patients to understand the benefit versus risk (side effects) that you, the caregiver consider with every prescription.

The questionnaires are given to waiting room patients, and determine if they are low, moderate, or high cost conscious OR have a low, moderate, or high concern about side effects. A scoring average will help the physician match the attitude with an efficacious medication.

An aspect of the educational value of the survey is an explanation that side effects may be transient or potentially permanent; or be "minor" such as muscle weakness, or life- threatening, therefore questions consider severity a primary consideration.

Unfortunately, in our experience, money-which includes even travel distance and gas costs affect doctor visits and even purchasing crucial medications. We are discussing an "ad hoc" survey of lifestyles, and priorities to realistically recognize other true/personal obstacles to health care which we see daily.

The point-scale attitude questionnaire has been very helpful in initial development. It needs to be updated only when insurance plans change, or, for personal reasons, attitudes have changed-we suggest annual updates.

We have begun the software-programming of the questionnaire and results. But the complexity of scanning the results and calculating scores, so far has been expensive, cumbersome, and requires special equipment. We believe this paper-based system is effective, for now.

The Metabolic Syndrome
(Insulin Resistance Syndrome)
PAGE 13

Obesity Hypoventilation Syndrome

The obesity hypoventilation syndrome, also known as Pickwickian syndrome, is the combination of obesity , falling oxygen levels in blood (hypoxia) during sleep and increasing carbon dioxide levels (hypercapnia); this is the result of hypoventilation (excessively slow or shallow breathing) during sleep. Obstructive sleep apnea is often but not necessarily present. Pulmonary hypertension is common and later causes cardiac arrhythmias.
SIGNS AND SYMPTOMS

Diagnosis

If OHS is suspected, various tests are required for its confirmation. Arterial blood gas levels are determined to measure oxygen and carbon dioxide levels; this requires a blood sample from an artery, usually the radial Page 14

artery. To distinguish various subtypes, polysomnography is required. To distinguish between OHS and various other lung diseases that can cause similar symptoms, CT scan, PFT’s and echocardiography may be performed. Criteria

Treatment

This chart is taken from the web page: there is about 700 calories per day difference between a very light and moderate activity level (that’s one pound a week!!! Activity Level:

Choose an activity level below to determine how many calories you burn a day.