CSOWM Study Guide (Free Resource)

Because I love you and I love evidence-based guidelines and I want you all to use what you can to help yourselves or someone else!

If you’re not sure what a CSOWM is, its a bunch of letters you get to add behind your name as a credential that says you are a “Certified Specialist in Obesity and Weight Management.” If you want to learn more about who can take this certification, what’s required, how expensive it is, or the content tested, go here: https://www.cdrnet.org/interdisciplinary. That is where you can also find all the official citations and references!

Overall, I thought the exam was pretty easy and covered exactly what it said it would. It was low on critical thinking and high on regurgitating evidence-based standards, terminology, and core knowledge. I honestly wish it had case studies or “problems” to solve, but it didn’t beyond calculating a BMI. Lame.

To prepare for the exam, I did two main things: 1. Lived, breathed, ate, and worked in the Obesity Management Space for a solid two years after dabbling in it personally and professionally for eight years prior, and 2. I bought this training course from the Academy:  https://www.eatrightstore.org/product-type/study-guides/obesity-and-weight-management-multidisciplinary-study-guide . Well, I didn’t buy it, I used my education stipend from work! Yay me.

Okay, so, because I’m nice and too lazy to figure out how to sell this as a digital product (if you love this, please subscribe or refer a friend; it really helps me a lot!), here in the following however many lines it takes for me to type this up, are my notes from the above course and the supplemental academic papers that were recommended to review! Now, don’t get too excited, this is NOT going to be all you need to know to pass. Consider these the highlights that stood out to me! A review of sorts. The random fun facts and numbers and charts and shit that are required to be memorized to get some answers right. 

And well, even if you aren’t studying for this exam, I hope you find it at least interesting and informative for your understanding of Obesity Management (and related topics) in our current healthcare space (for better or worse, but alas, endorsed by the major orgs that care about such things).

Here we go, in no particular order…

BMI classifications
< 18.5 underweight
18.5 to 24.9 Normal Weight
25 to 29.9 Overweight
30 to 34.9 Obese Class I
35 to 39.9 Obese Class 2
> 40 Obese Class 3

Office-Based Strategies for Treating Obesity (PCP focus) - 2016 paper
Calculate BMI on all pts at all visits and evaluate trends
Encourage an increase in Physical Activity and Improved Nutrition for Weight Loss
Recommend Medications for BMI > 30 or BMI > 27 w/ wt related comorbidity
Recommend Bariatric Surgery Eval for BMI > 40 or BMI > 35 w/ wt related comorbidity.

Use Motivational Interviewing techniques—includes patient-reported scales for Motivation and confidence; use the Decisional Balance Technique to explore ambivalence: Pros/Cons of Change vs. Pros/Cons of No Change; this helps to understand motivations and barriers; listen for change talk, provide encouragement, and enhance confidence. 

Tips for Office-Based Motivational Interview: 

• Ask permission, are they open/receptive to discussion?

• Use Empathy, Build Rapport & Trust

• Scale Motivation, Determine Readiness to Change

• Scale Confidence, Identify Barriers

• Use Curiosity, Ask Questions

• Pros Cons of Change vs No change (decisional balance)

• Reinforce Positive Change Talk

• Let the Pt Generate the Ideas for Change

• Promote Ownership & Confidence 

• Set actionable, small goals to start 

Increase Awareness for Medications that can *Promote* weight gain…
Antidepressants - remeron, paxil, lithium etc
Antipsychotics - clozapine, olanzapine, risperidone, seroquel
CardioVasc Meds - amlodipine, metoprolol, nifedipine, prapranaol
Diabetes Meds - insulins, meglitives, sulfonylureas, thialzolinolds
Hormones - estrogen, steroids
Seizures - carbamazepine gabapentin, lyrica, valproate

Micronutrients of Concern at risk for deficiency in people with Obesity:
Iron, b12, Folic Acid, Zinc & Vti D

The best equation for prediction of Energy Needs:
Mifflin St Jeor Eq
Males: 10xKg + 6.25xcm - 5x Age + 5
Females 10xKg + 6.25xcm - 5x Age -161

Multiply x activity factor  Sedentary 1.0; Low 1.4; Active 1.6; Very Active 1.7-2.5
For weight loss, subtract 500 to 750 calories.

Weight loss depends on calorie restriction; macronutrient ratios are not impactful in the long run as long as protein is adequate (RDA) and meets patient preference.

Supervision & Social Support play a significant role in adherence.

Social Ecological Model of levels of Greatest Impact → Lesser Impact:
Structure/Systems → Community → Institutions/Orgs → Interpersonal → Individuals

Equity “Highest level of health possible for all people; addressing the avoidable inequalities, historical injustice and health care disparities”

SODH includes social structures, economic/political systems, societal/cultural factors, and allocation of money/power/resources 

American Heart Association Recs for obesity management

Check BMI and Measure Waist Circumference at annual visits
“Healthy” Waist Women < 35”; Men < 40”
High BMI and/or High Waist increases the risk for Heart Disease.
“Modest Weight Loss” of 3-5% improves heart health.

Weight Loss Nutrition requires energy deficit and recommends diet:
1200-1500 calories for women; 1500-1800 calories for men OR 500-750 calorie deficit
There is no evidence that macronutrient balance matters; various dietary patterns are acceptable (low carb, Mediterranean, vegetarian, vegan, high protein, high carb) per pt preferences and cultures. Generally recommend decreasing high carbohydrate foods, increasing fiber, decreasing saturated fats

Refer to a registered dietitian for counseling or a “comprehensive lifestyle Intervention Program” definited as > or = to 14 session sin a 6 months period, individual or group, ON SITE/IN PERSON preferred, focus on decreasing calories AND increasing physical activity.
Telehealth and Commercial Programs are acceptable options but often show less results
The goal is to achieve 5-10% weight loss / 6 months.

Very rarely can use “Very Low-Calorie Diets” of < 800 cal per day in limited circumstances or extreme need for weight loss, under the supervision of trained professions and ideally in an in-person or residential medical setting.

For maintenance, continue calorie-restricted diet indefinitely to maintain new lower body weight; PT is encouraged to participate in a dedicated maintenance program for at least 1 year after weight loss is achieved, ideally face-to-face, but phone or telehealth is acceptable, at minimum monthly (or ideally weekly) intervals. Strong emphasis on increasing physical activity to 300 minutes per week. I recommend self-monitoring of body weight weekly or more frequently.

AHA supports Bariatric Surgery BMI > 35 w/comorbidities or BMI > 40 if pt does not respond to the behavior program with or without medications; refer to a high volume bariatric center and bariatric specialist for evaluation; goal for weight loss w/ surgery of at least 20 to 35%. “Insufficient evidence to endorse bariatrics for BMI < 35”. Specific procedure depends on a variety of factors, AHA does not make recommendations for this.


Behavioral Treatment of Obesity (Psych Paper 2011)
References the Look AheadTrial as model for comprehensive care:

The ideal comprehensive program consists of weekly sessions x 4-6 months, groups 10-15 people, 60-90 minutes long, with weight checks, a professional facilitator teach new skill each session.

3 main components of behavior change: goal setting, self-monitoring, and stimulus control
Goal Setting: 0.5-1kg per week wt loss, targeting 10% wt loss at 6 months + behavior goals
Self-monitoring: systematically recording target behaviors; are they improving, deteriorating or maintaining? Self-assessments include food logs and physical activity logs, enhanced by adding hunger levels, mood, place, time, etc.
Stimulus Control: intentional change to both internal and external cues associated with targeted behavior or eating plans; ex: change environment to increase visibility of healthful foods or setting out workout clothes at night to cue for morning walks.

Behavior/Lifestyle only Wt Loss Expectations: 8-10% weight loss = success

Weight loss usually peaks at six months; 80% of participants complete the program; Avg weight loss 5% and only 28% of those who complete the program achieve > 10% weight loss in one year; On average, all participants regain 33% of weight loss in the first year; 50% of participants regain to original weight within 5 years. 

→ Weight maintenance required long-term vigilance with long-term provider/program contact
Behavior change + Calorie Restriction required long term for durability
A high frequency/duration of Mod-Intensity Physical activity (walking) is most Important for maintenance; recs a minimum of 30 min per day every day to limit/reduce degree of weight regain, ideally those who engaged in > 275 minutes per week (60 minutes per day most days) were most able to maintain weight loss > 10%.

Pharmaceutical Management of Obesity (per Endocrine Society Paper)
Antiobesity Medications are an adjunct to lifestyle 
Appropriate for BMI > 30 and/or BMI > 27 w/weight-related comorbidities
Comorbidities: HTN, Hyperlipidemia, DM2 (diabetes), OSA (obstructive sleep apnea)
Weight loss of > 5% over 3 months is considered success = continue
Dosing should be based on efficacy & tolerability
Monitor Waist Circumference

Medical Causes of Obesity:
Syndromes: Prader-Wili, Barget-Biedi, Cohen, Alstom, Froehlich
Genetic Disorders: Melanocortin-4, Leptin Deficiency, POMC Deficiency
Neurologic: Brain Injury, Brain Tumor, Cranial Irradiation, Hypothalamic obesity
Psychological: Depression, Binge Eating Disorder
Endocrine: Hypothyroid, Cushings, GH Deficiency, Pseudohypoparathyroid
Drug-Induced: Antidepressants, contraceptives, antipsychotics, anticonvulsants, glucocorticosteroids, sulfonylureas, Giltazones, Beta Blockers, Insulin

NIH DM/Kidney Paper on Prescription Medications
Weight loss of just 5-10% significantly improves comorbidities

Medications can assist w/ adding 3-12% more weight loss than diet/exercise alone

Meds are appropriate for BMI > 30 and/or BMI > 27 w/ comorbidity
Most weight loss offers in the first 6 months of medication therapy.
If weight loss is < 5% over 12 weeks it is considered ineffective and should be discontinued
Medications in combination calorie-restricted diet and physical activity
Recommended PA = 150 minutes per week moderate intensive (75 minutes vigorous intensity) + 2 days of strength training per week.

4 meds approved for pediatrics (ages 12+): 
Orlistat (Xenical)
Liraglutide (Saxenda)
Phentermine-topiramate (Qsymia)
Semaglutide (Wegovy)
– very rare use for setmelanotide (imcivree) ages 6+ for rare genetic causes

6 Meds approved for adults: 
Orlistat (Xenical) - 3 pills per day with meals, decreases fat absorption, Alli is the OTC low dose version; do not use with history of Cholestasis
Bup/Nal (Contrave) - antidepressant/antialcohol/smoking med; do not use with history of hypertension, seizures, MAOIs, Opiods 
Phentermine-Topiramate (Qsymia) - decreases hunger and increases satiety, do not use with glaucoma, hyperthyroid, MAOIs, antidepressants 
Liraglutide (Saxenda) Semaglutide (Wegovy) GLP-1s
Tirzepatide (Zepbound) - GLP-1/GIP

Nutrition: Dietary Guidelines for Americans (USDA 2020)

Rates of disease (adults): Hypertension 45%, Diaebtes 11%, Prediabetes 35%, Hyperlipidemia 11%, Overweight/Obesity 74% (highest obesity at ages 40-59; 20% class 1, 8% class 2, 6% class 3); Osteoporosis in 17% of women and 5% of men. 6-9% of pregnant people are Dx with Gestational Diabetes (possibly under identified) 

Heart Disease is leading cause of death in the US, Stroke is #5 

Most common Cancers: Colorectal for men; Breast for women
59% of Americans Adhering to the DGAs in 2016 (self-reported, likely inaccurate) 

Key components of the DGAs: Nutrient Density, Variety & Portion Size Control
→ Personalize Nutrient Dense Foods based on Preferences, Culture & Budget
→ Meet Food Group Needs while also staying within Calories
→ Generally: Reduce added sugar (< 10% total calories), Reduce Saturated Fat (< 10% total calories), Reduce Sodium (2300mg/day for healthy adults); and Reduce Alcohol (1 per day or 

less for women, 2 per day or less for men); Limit Caffeine to 400mg per day for healthy adults

Adult Healthy Meal Pattern (2,000 calories) includes:
- Vegetables of all colors (2.5 cup per day)
- Whole Fruits (2 cup per day)
- Starches: at least half of all Grains from Whole Grain Sources (6oz per day)
- Fat Free or Low Fat Dairy and/or Soy alternatives (3 cup per day)
- Protein Foods (lean meats, legumes, nuts, seeds, seafood, eggs, soy) (5.5oz per day plus 8oz seafood per week, 5oz Nuts/Seeds per week)
- Healthy Oils/Fats (veg oils, fatty seafood, nuts) (27g per day
- <240 calories per day (~12% total cal) from added sugars, sat fat and/or alcohol

Adult Physical Activity Guidelines: 150-300 minutes Mod-Intensity per week (brisk walk) plus strength training 2x per week (vague guidance here on duration or intensity)

Pregnancy Additional Calorie Needs:
1st trimester zero calories
2nd trimester + 340 cal
3rd trimester + 452 cal
Lactation 0-6mo + 330 cal
Lactation 6-12 mo + 400 cal

Pregnancy Weight Gain Guidance per BMI:
< 18.5 underweight  28-40lbs, 1lb per week of 3rd trimester
18.5 to 24.9 Normal Weight 25-35lbs, 1lb per week of 3rd trimester
25 to 29.9 Overweight  15-25lbs, 0.6lbs per week of 3rd trimester
> 30  Obesity  11-20lbs, 0.5lbs per week of 3rd trimester

Pregnancy Key Notes…
Folate 400-800mcg, starting 1 mo prior to conception (Folic Acid 0.4-1mg)
Iron ~ 27g or per HC provider + Vit C
Iodine 150mcg; fdairy, eggs seafood, table salt
Vit D 200-600 IU
Choline, 450mg; usually inadequate in prenatal MVIs, eggs, beans, peas, fish, dairy
Seafood from low mercury sources like can tuna, salmon, trout, sole 8-12oz per week
Zero Alcohol; No protein suppleents, No herbal Supplements, No Raw Seafood, No Unpasteurized Milk or Juice
Caffeine 300mg pr less per day
Pregnancy PA 150 mins per week of mod-intensity or 30 minutes most days (contraindications ruptured membranes, severe hypertension, multiple gestation at risk for preterm delivery, placenta privera, extreme obesity)

Infants: exclusive BF x 6 months OR iron-fortified formula, start vit D supplements at birth, add complementary foods at 6 months, prioritize iron, zinc esp for BF babies

40% of adolescents have Overweight/Obesity 

Calorie Needs for Age:
Ages 2-4 1,000-1400 (girls); 1,000-1600 (boys)
Ages 5-8 1,200-1,800 (girls); 1,200-2,000 (boys)

Pediatric Nutrition Priorities:
Decrease Fast Food, Increase Whole Foods

Decrease Added Sugars
Appropriate Portion Sizes
Zero Sugar Sweet Beverages
Decrease Sat Fats

Decrease High Sodium Foods
Increase Fiber to RDA

Offer Timely Meals, Responsive Feeding, Family meals
Avoid Mindless Eating, Boredom Eating, Behavior Management w/ Food
Limit Screen Time: Ages 2-5 1 hour per day; School Age 2 hours per day

Pediatric Recommendation for Physical Activity
Toddlers: 3+ hours per day ; School Aged: 60 mins per day (mod-vig unstructured play) plus muscle/bone activity 3x per week (structured sports)

Daily Recommended Sodium Targets
1200mg age 1-2
1500 mg age 4-8
1800mg age 9-13
2300mg age 14+
Current average US sodium intake: 3393mg/day (2,000-5,000/day)

Alcohol “Standard Drink”, Alcohol = 7 calories per gram
12 fl oz Lite Beer 5% ABV = 150 cal
5 lf oz Wine 12% ABV = 120 cal
1.5 fl oz 80 proof spirit 40% ABV = 100 cal
7 fl oz Rum 40% w/ Cola = 190 cal

Older Adult Considerations: Adequacy to prevent unintentional wt loss; Increase Enjoyment of meals (liberalize the diet from restrictions), Safety for Chew/Swallowing, Food Safety, Preparation, and Shopping Abilities

Federal Food Assistance Programs to know: WIC, SNAP, CACFP (daycares/adult daycares), National School Lunch, National School Breakfast, SFSP (Summer School Foods); FDPIR (Indian reservations); Healthy Hunger-Free Kids Act of 2010 significantly increased funding to school foods programs


Adult Bariatric Metabolic Surgery (ASMBS 2016) 

BMI > 40 or BMI > 35 w/comorbidity
(for the purpose of this exam this is the standard, although there have been recent changes to do bariatrics for BMI > 30 w/ comorbidity and BMI > 35 w/o, especially in light of Anti-obesity medicine cost vs. safety, clear benefit, affordability and durability of surgery)

Procedures - review anatomy: VSG, RNY, Band, Switch, Balloons; Review metabolic changes (leptin, ghrelin, insulin resistance, etc)

Post Bariatric Supplement Guidelines (Sleeve & RNY are the same unless otherwise stated)
Iron - men or postmenopausal 18mg/day; mestrurating 45-60mg - separate from Calcium Supplements
Folic Acid: 400 to 800mcg via multivitamin; 800-1,000mg if childbearing potential
Thiamine: 12mg via multivitamin, additional 50mg via b-complex
Copper: 100% of RDA in MVI (increase to 200% for RNY)
Zinc: 100% of RDA
* Zinc to Copper ratio of 8:1 to prevent copper deficiency
B12: oral 300-500mcg per day
D3: 3,000 IU per day
AEK: RDA via multivitamin
Calcium: 1200-1500mg per day, broken up into 2-3 dose (separate from iron) - Citrate is better absorbed via RNY, carbonate cheaper and okay for VSG

Daily Supplement regime may include 1-2 multivitamins, B complex or B12, Calcium, Iron if not included in multivitamins, all with different administration timing (6-8 supplements per day)
Recommend PCP to check levels on annual physicals
Can ask for b12 monthly SQ 1,000mg at home if appropriate

Bariatric Concerns:
Cholelithiasis (kidney stones, often from oxalate) - prevented with/ adequate calcium intake (binds and passes oxalate), low Ox diet may help, avoid dehydration, add probiotic Oxalobater
Cholecystectomy - gallbladder removal after severe weight loss; some surgeons now recovering gallbladder at time of bariatric sx
Limit Alcohol, risk of abuse s/p sx
Limit NSAIDS, risk of gastric irritation.
Postpone Pregnancy at least 12 months, really 18+ or until weight loss has stabilized and maintained, fully tolerating regular diet in full portions.
High risk for worsening GERD with Sleeve
Most revisions currently are Band to sleeve or Sleeve to Switch


Bariatric Sx Weight Loss Expectations:
Band (rarely used currently) 20% wt loss at 2 years ,14% at 10 years (many removed by then)
Gastric Sleeve 25% at 2 years; not much long term data for durability 
RNY 35% at 2 years; 25% at 10 years
It is important to manage expectations, emphasis on expectations for regain and strategies to prevent, stress the importance of lifestyle, behavior, environment, nutrition and physical activity changes. 
Inadequate Weight Loss is considered weight loss < 20% after VSG or RNY
10-20% of surgical patients daily to lose 20% body weight
About 20-25% of weight initially lost is usually regained (if lost 100lbs, usually regain 25lbs) over 10 years after surgery.
“Bariatric Surgery does not Cure Obesity, it is a Chronic Disease”
Continued exposure to obesogenic environment influences energy balance.

Individualized Assessments & Counseling Related to Modifiable Lifestyle Factors to Prevent Weight regain after Surgery …
- Role of Processed Foods vs Whole Foods
- Nutrition Quality and Portion Size Goals
- Food Shopping, Cooking Skills
- Mindfulness Practices, Hunger/Fullness Cues
- Gut Health, Microbiome, Fiber
- Regularity of Eating Patterns (no skipping meals, bingeing/restricting?)
- Night time eating syndrome (increased ghrelin at night)
- Physical Activity
- Managing Sleep and stress (impacts insulin resistance and food choices)
- Weight Promoting Medications
- Life Changes, pregnancy, menopause
- Family Changes, divorce, new relationships, death of parents, job change, move
- Dining Out, Traveling, Vacations

Micronutrient Deficiencies Signs and Symptoms

Bone/Muscles:
D - depression, muscle pain, osteoporosis
Calcium - decreased bone density, osteoporosis, pain
Magnesium - contractions, osteoporosis, pain

Anemias: 
Iron - fatigue, spoon nails, glossitis
B12 - numbness, tingling, fatigue, depression, ataxia
Folic Acid- palpitations, fatigue, pale skin
Zinc - skin lesions, decreased wound healing, hair loss, taste changes
Copper - gait changes, tingling limbs, decreased wound healing, paralysis

Neuro:
Thiamine - confusion, ataxia; Dry BeriBeri = convulsions, weakness, extremity pain, brisk tendon reflexes; Wed Beriberi = tachycardia, acidosis, shortness of breath; Wernicke Encephalopathy = confusion, ataxia, hallucinations, psychosis

Fat Solubles:
A - night vision, dry hair, poor wound healing, decreased immunity
K - easy bruising
E - weakness, gait changes, ataxia


Micronutrient Repletion Guidelines:
Thiamine - PO 100mg 2-3x per day until symptoms resolve or IV 200mg 3x daily for 2-5 days, then 100mg oral indefinitely
Vit D - 50,000IU per week for 8-12 weeks if 25ohD<20 OR 2-6k IU per day f decrease on dexa and increased alk phos (severe deficiency)
Folate - 1mg daily until normal
B12 - 1,000-2,000mcd daily or 1,000mcg IM per week
Iron - 150-200mg elemental BID or TID (sep from calcium) until normal then EOD at RDA

Pediatric Obesity Management (2015 Guidelines)

BMI > 95th% = Obesity
BMI > 85th % = overweight 
BMI 5-84th % = healthy
BMI < 5th % = underweight

Pediatric Obesity Treatment goal is to achieve a BMI < 84th % and practice healthy lifestyle behaviors using “Chronic Care Model”

Pediatric Obesity Prevention Target Behaviors: (key: + means increase, - means decrease)
+ calcium, + fiber, -energy dense foods, - sugar sweet bev, + fruit/veg (9 serves a day), - screen time (<2hrs day), - fast food, + family meals, + portion control, daily breakfasts, +balanced meals, + BF x 6 months, + PA (60min/day)

The Pediatric Physical Exam for Pt w/ Obesity, make a note of…
Anthropometrics - BMI, Stature, Blood Pressure
Skin - acanthosis nigricans (insulin resistance); acne, hirsutism (facial hair in girls = PCOS), irritation & inflammation
Eyes - papilledema, nerve IV paralysis (tumor?)
Throat - tonsillar hypertrophy (sleep apnea)
Neck - Goiter (hypothyroid)
Chest - Wheezing (asthma)
Abdomen - tender (NAFLD, GERD, Gallbladder disease)
Reproductive-tanner stage (early puberty), undescended testes (prader-willi)
Extremities - abnormal gait, bowed legs 

Pediatric Eating Assessment: via 24-hour recall, food logs, and/or food frequency questionnaires -requires parental involvement; includes… Fast Food Frequency, Sugar Sweet Bev, Portion Sizes, Oz of Juice, Frequency and Quality of Breakfast, # Fruit/Veg, # meals/snacks, Screen Time, Family Meals; PA?, Sedentary Time? Routine Activity (walk to school?)


Pediatric Interventions, Chronic Care Model, Staged Degree of Intensity:
(If 3-6 months without progress at each stage; move to the next)

Stage 1: Office Based, Primary Care Provider (3-6 mo visits)
Recommendations: > 5 serves fruit&veg/day; < 1 serve SSBev/day, < 2 hours Screen Time /day
Unstructured Play PA > 60mins/day; Prepare more meals at home; eat at the table as a family, involve the whole family in changes; eat daily breakfast; honor culture/preferences, avoid overly restrictive methods/diets; allow self-regulation of meals and snacks/portions needed for hunger, etc. 

Stage 2: Registered Dietitian Referral, “Structured Weight Management” (monthly visits)
Planned daily meal plans that meet the RDAs, structured/scheduled meals and snack times, Screen time < 1 hour per day, Supervised PA 60 mins/day, Monitoring Food and Activity Logs, Planned Positive Reinforcements for achieved behaviors

Stage 3: Pediatric Obesity Treatment Center, Specialists, “Comprehensive Multidisciplinary Intervention” increased intensity, frequency of visits “maximal outpatient support,” weekly office visits x 8-12 weeks, then monthly after that. Weekly evaluations of weights.
Structured Plan - Food monitoring, Specific Nutrition and PA pals, Contingency management planning, negative energy balance targets prescribed; strong participation from parent, including education and training to adults for significant home environment changes.
Multidisciplinary team of RDs, Doc, Social Worker, Psychologist, Exercise Physiologist, and Support Staff, etc.

Stage 4: “Tertiary Care Intervention” - highest level of care; weight management mediation and/or bariatric surgery evaluation; VLCD has very little evidence or support - rarely used; Weight loss sx appropriate if growth plates are closed, generally for girls at age 13+ and boys at age 15+; usual s/p intensive pre-operative education and preparation program, includes multidisciplinary team; Risk for being lost to follow up, Concern for affordability and adherence to vitamin/mineral supplementation.


Pediatric Bariatrics ASMBS Practice Guidelines
25% of adults with obesity had childhood obesity
There is a positive role for sleeve & RNY in adolescents, proven safe & effective.
Criteria: BMI > 35 w/comorbidity (girls < age 18 with a BMI of 35 are at the 99th %)

Pediatric Comorbidities

Strong Indicators of Benefit of Bariatric Sx:
Type 2 Diabetes: + risk for heart disease, NASH; see remission of DM w/ RNY (comparatively DM is extremely difficult to manage in pediatrics w/ behavior/nutrition/PA alone)
OSA (obstructive sleep apnea): seen in 20% of kids with obesity - fatigue, school trouble
NASH: 38% of kids w/ obesity have early steatosis, 9% have NASH, Bariatric sx = regression of fibrosis
Pseudotumor Cerebi: Increased cranial pressure “false tuor” improves w/in months

Less strong Indicators of Benefit of Bariatric Sx:
Cardiovascular Disease - lacking evidence of risks and benefits
Metabolic Syndrome (hyperinsulin, insulin resistance, increased lipids) - ill-defined standards for metabolic syndrome in kids
Decreased Quality of Life Related to Obesity (poor self image, bullying) - can be improved w/ surgery but requires comprehensive and sensitive approach w/ appropriate counseling
Depression: not an automatic exclusion criteria but requires close mental health care follow up, we do see slight uptick in Suicidal Ideation w/ pediatric obesity potentially improved w/ Bariatric Sx, more research needed.
Eating Disorders: 5-30% of kids w/ obesity suffer from Binge Eating Disorder, not well studied related to bariatric surgery, more research needed; If previous ED is treated and resolved prior to surgery, it is not an automatic exclusion criteria

Risks of Bariatric Surgery in Pediatrics:
- Nutritional non-compliance
- High risk for deficiencies, especially thiamine
- RNY - concern for iron, b12, D, calcium r/t growth and long term health
- Weight loss increases fertility, counsel to avoid pregnancy for at least 18 months, add contraceptives, sex education
- often lost to long-term follow-up, loss of insurance coverage in 20s

Diabetes Standards of Care

Chronic Care Model is collaborative and multidisciplinary, and has 6 core elements:
1. Proactive approach
2. Self Management Support
3. Healthcare Decision Making Support (evidence-based guidelines)
4. Utilizes Clinical Information Systems
5. Includes Community resources and Policy effects on SODH food insecurity, housing, transportation, language barriers, telehealth access
6. Addresses the role of Health Systems, promotes quality oriented culture

A CCM model has been shown to decrease heart disease, decrease the rate of medical complications/errors, decrease mortality and decrease healthcare spending.

Classifications and Diagnosis of Diabetes

Type 1: autoimmune, Bcell destruction = insulin deficiency, typically dx at age < 35; BMI < 25, presents w/ DKA, weightloss and/or glucose > 360; sometimes dx as Latent Autoimmune Diabetes in Adults (LADA). Screen for autoimmune thyroid disease and celiac disease.

Type 2: progressive loss of adequate B cell secretion of insulin = insulin resistance and/or metabolic syndrome; B cell demise over time/progressive, genetic, metabolic and inflammatory causes. Dx w/ fasting glucose > 126 OR 2 hour post 75g OGTT > 200 OR A1C > 6.5%
OR signs/symptoms of diabetes (wt loss, frequent urination) + random glucose > 200
* for OGTT test need to have eaten at least 150g arbs x 3 days prior

PreDiabetes: A1C > 5.7%, fasting 100-125; 2 hour post 75g OGTT 140-100

Gestational Diabetes = pregnancy, hormonal, increases risk for DM2 later in life, increases risk for large baby at birth (Macrosomia)
Drug Induced Diabetes = s/p steroids, HIV/AIDS, Transplant
Exocrine Pancreas Diabetes = s/p severe pancreatitis, cystic fibrosis, pancreatic cancer ; Should Screen for pancreatic cancer if newly dx with diabetes without family history and if presenting in a lean body habitus with out risk factors. Bidirectional relationship between DM & Pancreatitis.

Conditions that impact the accuracy of the A1C / Glycemia Relationship: Sickle Cell, Pregnancy/Post Partum, Glucose 6 phos dehy deficiency, HIV, Hemodialysis, Blood Loss/Trauma/Transfusion, Procrit therapy, Cystic Fibrosis

Diabetes Screening should occur if BMI > 25 (overweight)+ risk factor and/or age 35+. Rescreen every 3 years if normal. Screen Pediatrics at age 10 if BMI > 85th % (overweight). All people with HIV/AIDS should be screened before antiviral tx. If Hx of Gestation DM should screen for diabetes every 3 years for life.

Risk Factors for Diabetes: Relative w DM, African American, Latino, Asian or Pacific Islander, Hx of Heart Disease, Hypertension, HDL< 35, Triglycerides > 250, PCOS, Physical Inactivity or presence of Ancanthosis Nigricans (dark neck/skin folks)

Diabetes Prevention:  If considered a risk for diabetes (overweight + risk fator) a 7% reduction in weight with a reduced calorie diet and > 150min/wt mod intensity PA can prevent DM progression. Refer to  “Diabetes Prevention Program” = intensive lifestyle program of 16 sessions of structured curriculum; Variety of acceptable eating patterns, individualized care, social and provider support, focus on nutritional quality and whole foods.  Add Metformin in all w BMI > 35 and A1C > 6%.  Metformin can cause b12 deficiency; add a supplement.

Characteristics of Comprehensive Care Approach:
- Person-Centered Collaborative Care
- Culturally Sensitive
- Strength-Based and Person First Language
- Active Listening
- Elicits Individual Preferences
- Assesses Literacy, Numeracy
- Assessed Barriers
- Aims to optimize health related quality of life
- Shared Decision making
- SMART goals
- ongoing support and monitoring 
- non-judgemental
- free from stigma
- respectful, inclusive, hopeful
- fosters collaboration

Coordinated Multidisciplinary Team includes Diabetes Educators, PCP, Endocrinology, Bariatrician, Dietitian, Exercise Physiology, Pharmacists, Dentists, Podiatrists, Mental Health, Nurses, Medical Assistants, Office Staff etc …. Patients with Diabetes should be referred to evaluations for: Eyes, Family Planning, Dietitian, Diabetes Self Management Education, Dentist, Mental Health, Audiology, Social Worker, Wound Care, Podiatry, Sleep Study, Sexual Health Eval,etc

Strongly recommended to remain up to date on all routine vaccinations.

Evaluate for Hypoglycemia Risk: insulin, CKD, Liver disease, longer duration of diabetes without treatment, frailty/old age, cognitive impairment, developmental delay, hypoglycemia unawareness, physical or intellectual disability, alcohol abuse, polypharmacy (esp ACE inhibitors), lives alone, food insecurity, hearing or vision impairments.

Diabetes Glycemic Targets
Goal A1C < 7% (avg glucose x 3 months ~ 154)
Advanced age or frailty, goal ~ 8% (avg ~183) - de-intensify treatment w/ age
If CGM, wnt to see 70% of time “in range” and < 4% of time below normal

Goal glucose premeal 80-130; Post Meal < 180

Hypoglycemia Levels: 1 < 70; 2 < 54, 3 severe physical symptoms
s/s of hypo: shakiness, irritability, confusion, tachycardia, hunger
Treat with glucose, glucagon or high CHO snack w/o NO fat

Obesity and Weight Care with Diabetes
Check BMI at annual visit, monitor trends, if sudden change rule out Heart Failure
Accommodate a positive weighing experience.
Encourage weight loss 3-7% for improved glycemia, ideally > 5%
Encourage weight loss > 10% for more benefits and long-term outcomes
BMI 25-27: nutrition, PA, behavioral counseling
BMI 27-30: add pharmacology
BMI > 30: refer to metabolic surgery
Nutrition goals: adhere to a 500-750 calorie deficit; Refer to Dietitian for MNT x 16 sessions over 6 months fo individualized care, eval social/structural barriers, add maintenance program at 1 year after weight loss; VLCD only very short term (<800 cal), No evidence of benefit of any OTC supplements for weight loss. 

→ LookAhead trial: mean wt loss was 4.7% at year 8
50% maintained > 5% wt loss, 27% lost and maintained > 10%
Women 1200-1500 cal / Men 1500-1800 cal


Metabolic Surgery for Diabetes (indicated If BMI > 30)
Recommended at high volume centers w/ eerpeince, long term pre/post op support
VSG removes 80% of the stomach
RNY walnut size pouch, bypass duodenum and jejunum
RNY achieves diabetes remission in 30-60% of patients; most remain disease-free up to 8 years; 30-50% eventually do have a recurrence of diabetes.
Higher risk w/ hx of diabetes for Dumping Syndrome ~ 20mins post meal; Delayed Reactive Hypoglycemia ~ 1+ hour post meal, may be worthwhile of add CGM, may have over production of insulin complicating the delayed nutrient absorption.
Monitor for Risks w/ Bariatric Sx: Vit/Mineral deficiencies, Anemia, Osteoporosis, Substance Abuse, New Anxiety/Depression

Cardiovascular Risks with Diabetes
Hypertension is diagnosed at 130/80 x 2 readings in office or 1x reading at 180/110; lower safe limit of BP after treatment 90/60
Daily home BP monitoring is recommended w/ DM + HTN

Diet Intervention: DASH Diet, low Na, High K, No Alcohol, increase PA (150 mins), 8-10 servings of fruits and vegetables, 2-3 servings of low fat dairy or soy
Hyperlipidemia diet: decrease sat dat, increase omega 3s, increase viscous diners, increase plant sterols/stanols, increase PA; also appropriate “Mediterranean Diet” however poorly defined. 

Soooo yeah, that’s the end of my “notes”. I’ll add that I had questions on the PAR-Q pre-fitness screening process (healthy enough to exercise? Answer is almost a yes, at least low/slow, but if a risk, need clearance). Also had questions on Bariatric diet modifications (puree vs regular, easy) and post surgical ambulation (early, often). I had some questions on Sleep Apnea that were pretty vague and some questions on weight management medications and pregnancy (don’t use them).

Sadly it seems this exam doesn’t really care about GLP-1s… liraglutide was mentioned as an option to add to help manage Bariatric surgery regain (duh)…. But semaglutide and trizepatide did not exist.

So, throwing it out there: Dietitian Academy & CDR folks, if you’re listening (or if any of my dietitian friends know a guy) HIRE ME to review the evidence, film a webinar and write some Qs on THE FUTURE of obesity medicine for the next gen that takes this exam!

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