Behavioral Medicine Final Exam (new content)

What are 3 people groups noted to live in Ohio?

Somali, Nepalese/Bhutanese, Latin American

According to Bhuwan Pyakurel, what is the biggest honor you can give a person?

Consider them as a human being

What are some ways you can make a patient feel safe and experience human dignity?

- treat patients with disabilities as the adults that they are

- shake hands and make eye contact (sit at the level of a person in a wheelchair, etc)

- don't get in someone's personal space

- don't raise your voice

- ask before assisting or moving someone with limited vision or mobility

What are the 10 universal tips to practicing cultural competence?

1. ask patients what they need and how they would like to be addressed

2. outline your commitment to being culturally competent and ask pt to let you know if you offend

3. teach-back

4. for some cultures, a personal relationship with provider is part of what healthcare means--acknowledge this limitation in US but strive for trusting, professional relationship

5. advocate for hiring cultural specialists and navigators

6. participate in clinical intercultural collaboration and hold each other accountable

7. look for extra support from your staff/institution

8. develop accountability systems to check your biases

9. be patient-centered and make accommodations

10. Commit to ongoing professional development around disparities related to demographics, language, gender, race, ethnicity, and religion

What are the 3 goals of effective cross cultural competency?

1. understand illness from perspective of patient

2. assist patient in understanding disease and treatment from the perspective of biomedicine

3. to help patients and families navigate, express themselves, and feel comfortable in the healthcare organization

CC communication skills are best developed through

practice, reflection, reading about and interacting with diverse populations

What is culture?

defined by beliefs, values, rituals, customs, institutions, social roles, and relationships that are shared by a group of people

T/F the healthcare system is also a culture

true!

Biomedicine as a system of healing rests upon esteems the following

empiric science

written knowledge

rigorous training

technological sophistication

action orientation

materialism

reductionism

team-based care

efficiency

avoiding malpractice

prolongation of life

What is materialism as valued by biomedicine?

disease in the individual, physical body rather than in the family, social group, mind, or spirit

What is reductionism as valued by biomedicine?

pathophysiology is molecular and anatomic; symptoms are expressions of underlying disease rather than diseases themselves

What are some questions that may elicit a patient's explanatory model of illness?

What do you think caused your problem?

What do you think you have?

What is the name you give to this condition?

Why do some people get this illness but not others?

What do you think needs to be done to relieve this problem?

What is the explanatory model?

A patient's perspective on why they have a condition and their treatment

CAUSATION

What is fatalism?

patients who may be passive in seeking treatment and persisting in unhealthful behaviors and accepting of their misfortune; feeling of powerlessness often due to little control in life

T/F: Using a bilingual family member is appropriate means of translating for a patient

False

T/F: anxorexia and bulimia are diagnoses that represent specific diseases

F: clinical syndromes defined by a constellation of behaviors and attitudes over time

What is a multidimensional/stress-diathesis model?

psychological, biological, and sociocultural stressors contribute to development of syndrome

What psychological qualities are associated with anorexia nervosa?

obsessive-compulsive qualities, constrained affect, sense of ineffectiveness

What psychological qualities are associated with bulimia nervosa?

impulsivity

Define anorexia nervosa

Rare eating d/o & mental health condition characterized by an obsessive preoccupation w/food, dieting, weight and body shape

Discuss 2 subtypes of anorexia nervosa

- Restrictive type-wt loss achieved via dieting, fasting, or excessive exercise

- Binge-purge type

What are pathognomonic features features of anorexia nervosa?

an intense fear of gaining weight (relentless pursuit of thinness)

Discuss clinical features of anorexia nervosa

- Significantly low body weight (typically BMI of < 18.5)

- loss of body fat, scaly skin, increased lanugo

- Excessive exercise (compulsive)

- Often exhibit ritualistic behaviors associated with food

- Cold intolerance

- Bradycardia, hypotension, hypothermia (severe cases)

- Weakness, muscle aches, poor sleep, GI disturbances (constipation, bloating)

- Amenorrhea in women

- Binge-purge subtype

What BMI classifies mild anorexia?

17-18.49

What BMI classifies moderate anorexia?

16-16.999

What BMI classifies severe anorexia?

15-15.999

What BMI classifies extreme anorexia?

< 15

What is the goal of medical therapy for anorexia nervosa?

weight normalization, menstruation in females, and improvement of psychologic difficulties

What are essentials of diagnosis for anorexia nervosa?

A. significantly low body weight

B. intense fear of wt gain or persistent behavior that interferes w/ wt gain

C. one of the following:

- disturbance in body wt or shape perception

- undue influence of body wt or shape on self-evaluation

- persistent lack of recognition of the seriousness of current low body wt

What are treatments for anorexia?

- First correct acute medical complications

- Lab screening for electrolytes, liver function, amylase,

thyroid function, CBC with diff, and urinalysis

- EKG (QT prolongation, bradycardia)

- Treat dehydration and correct electrolyte disturbances

- Nutritional rehabilitation

- Re-feeding techniques

- Behavioral strategies

- CBT, Individual psychotherapy, and family-based herapy

(FBT)

- Pharmacotherapy (TCAs, SSRIs, Lithium) sometimes effective

Define bulimia nervosa.

- episodic uncontrolled ingestion of large quantities of food followed by recurrent inappropriate compensatory behavior to prevent weight gain

- both occur weekly and for at least 3 months

What are signs/symptoms of bulimia nervosa?

- Gastritis, GERD, esophagitis, dehydration, electrolyte disturbances

- Tooth enamel decay, parotid gland enlargement (recurrent vomiting)

- Often normal weight, sometimes overweight

What are potential compensatory behaviors related to bulimia nervosa?

purging (self-induced vomiting), laxatives, diuretics, excessive exercise, fasting

How do you differentiate anorexia binge-purge subtype and bulimia?

If pt underweight, amenorrheic, is binging and purging = anorexia nervosa of binge-purge type rather than bulimia nervosa

What are complications of bulimia nervosa?

gastritis, esophagitis, periodontal disease, dental caries, gastric dilatation and gastric or esophageal rupture, cardiac arrhythmias (often 2nd to metabolic alkalosis and

hypokalemia because of excessive vomiting), metabolic acidosis (esp. with laxative use), fatigue, and muscle aches

What are treatments for bulimia nervosa?

- Usually in outpatient settings or partial hospitalization programs or inpatient care if suicidality

- Cognitive behavior therapy

- Family-based therapy (FBT)

- Pharmacotherapy

- SSRIs (fluoxetine)

- Buproprion contraindicated may induce seizure activity (the metabolic imbalances can make pts more prone to seizure)

How do you classify obesity in adults?

BMI >= 30 kg/m2

• Class I (BMI= 30-34.9)

• Class II (BMI- 35-39.9)

• Class III (BMI>40) = extreme obesity

How do you classify obesity in children?

BMI >/= 95th percentile for age & gender

What is an overweight BMI in adults?

BMI 25-29.9 kg/m

What is an overweight BMI in children 6-18?

BMI >/= 85th-94th percentile for age & gender

What percent of US adults are obese?

39%

What percent of US adults are overweight?

35%

What percent of US children are obese?

18.5%

What percent of US children are overweight or obese?

33%

What is a genetic factor influencing obesity and body weight?

Resting metabolic expenditure (RME)

- 65-70% of total energy expenditure

- Those w/ lower RME will be heavier

What are environmental factors influencing obesity and body weight?

- sedentary lifestyle

- medical illness/disease (hypothyroid, depression, Cushing)

- meds (psychotropics, anticonvulsants, insulin, TZDs)

- high caloric intake

Obesity is a risk factor for...

- Type 2 DM

- HTN

- hypercholesterolemia

- Cancers (colon, ovary, breast)

Obesity is associated with...

- DJD

- GB dz, GERD

- Thromboembolism, stroke, HF

- OSA, restrictive lung pattern

- Skin conditions

- Depression

- Surgical complications

Prevention and screening for children with potential body weight disorders?

- USPSTF screen all children >= 6

- Comprehensive, intensive behavior intervention to promote improvement in weight status

- Dietary

- Physical activity

- Behavioral counseling

Prevention and screening for adults with potential body weight disorders?

- USPSTF screening for all adults.

- BMI

- Refer >= 30 kg/m2 to higher intensive, multicomponent behavior intervention

What is considered a high risk waist circumference in men?

> 40 inches

What is considered a high risk waist circumference in women?

> 35 inches

Calorie deficit for weight loss

- 500 kcal/day

Diet plan for weight loss

Low fat, high fiber

Fat 20-35% of daily calories

Carbohydrates 45-65% of daily calories

Protein 10-35% of daily calories

Weight loss is predicted by _______________ rather than macronutrient composition

adherence to diet

What is the role for VLCD?

very low calorie diet - questionable maintenance, weight loss needed quickly

Benefits of aerobic exercise

Burns lots of calories

Increase exercise tolerance

Sense of well-being

Decreased BP, better glycemic control, improved lipids

Decreased mortality from CV dz, and all other causes

Benefits of resistance training

Maintain lean body mass

Data from the national weight control registry indicates success when what aspects of weight loss are incorporated?

Low-fat diets

Low-calorie diets (~1400 cal/day)

Physical activity averaging 60 minutes/day

Regular self-monitoring of weight

Eating breakfast daily

Consistent eating patterns on weekdays and weekends

American College of Sports Medicine exercise recommendations

150 minutes/wk of moderate-intensity aerobic exercise

OR

75 min vigorous-intensity/week

OR

Combination of above

AND Resistance Training at least 2x/week

Who should be medicated for weight loss?

adjuncts to diet and exercise in pts with BMI > 27 with risk factors/diseases, or any pt with BMI > 30

What is the order of efficacy for weight loss medications?

Tirzepatide > Semaglutide > Phentermine/Topiramate ≈ Liraglutide > Contrave > Orlistat

Which weight loss medication is recommended by the American

Gastroenterological Association?

semaglutide

Who should be considered for weight loss surgery?

- pts with BMI > 35 and comorbid conditions

or any pt with BMI > 40

- Must be at high risk for obesity-related M/M

- Must have failed adequate wt loss with lifestyle modification w/ or w/o pharmacotherapy

- Must have stable psychiatric status

- Must be fully committed to lifetime lifestyle change

What are contraindications to weight loss surgery?

- Poor cardiac reserve

- COPD or respiratory dysfunction

- Severe psychological d/o

- Nonadherence to medical treatment

What are the 2 most common weight loss surgeries done in the US?

- Sleeve gastrectomy

- Roux-en-Y gastric bypass

What is adjustable gastric band?

Surgical procedure in which a band prevents the stomach from expanding but that can be adjusted surgically

What are long term complications of weight loss surgeries?

- Fat soluble vitamin deficiency (ADEK), B12, folate, calcium

- Weight regain (38% loss at 1 yr, 25% at 10 yrs in one study

Perioperative morbidity/mortality associated with weight loss surgery?

- 4% early morbidity (DVT, re-operation, >30 days in hospital)

- Mortality now similar to cholecystectomy and hysterectomy

How do you calculate BMI?

weight in kg/(height in m)^2

OR

[weight in lbs/(heigh in in)^2 ] x 703

1 inch = how many cm?

2.54 cm

1 kg = how many lbs?

2.2 lbs

What are the stages of coming out?

1. acknowledging

2. testing and exploration

3. identity acceptance

4. identity integration and self disclosure

Cisgender

Person who identifies with the gender they were assigned at birth

Nonbinary

Person who identifies as gender other than male or

female; Also an umbrella term to describe a spectrum of identities

Agender

Person who doesn't identify with a gender or combination of genders; genderless

Transgender

Person who identifies with a gender different than what they were assigned at birth

Genderfluid

Person who does not identify with a fixed gender

Genderqueer

Person who doesn't identify with a male or female gender identity

Lesbian

Person who identifies as a woman or is feminine aligned

who is attracted to other women/feminine aligned people

Bisexual

Person who is attracted to two or more genders

Asexual

Person who experiences little to no sexual attraction; Also an umbrella term to describe a spectrum of identities

Gay

Person who is attracted to people of the same gender; Also an umbrella term used by people who identify with a sexuality other than heterosexual

Pansexual

Person who is attracted to others regardless of their gender

Queer

Person who identifies with a sexuality other than heterosexual, but may or may not also identify with another label; Also an umbrella term to describe a spectrum of identities

Sexual identity =

gender identity

Gender expression =

behavioral manifestation of gender identity

T/F: A transgender man who has had "top surgery" does not need breast exams

False - not the same as a total mastectomy and breast tissue may remain

How should you navigate patients' sexuality and gender identity?

Stop assuming you know; ask for preferred name/pronouns

What medical/legal discussion should you make sure you have with your LGBT patients?

durable power of attorney

An LGBT patient may need extra grief support when?

After loss of partner, especially if excluded by partner's biological family

Opioids refers to _________ while narcotics refers to __________

prescribed med, illicit drug

How long is a heroin overdose in duration?

3-5 hours

What are symptoms/signs of opioid overdose?

respiratory depression, apnea, pulm edema, pinpoint pupils, coma, death

Describe grade 0 opioid withdrawal

craving, anxiety

Describe grade 1 opioid withdrawal

yawning, lacrimation, rhinorrhea, perspiration

Describe grade 2 opioid withdrawal

yawning, lacrimation, rhinorrhea, perspiration, mydriasis, anorexia, tremors, hot/cold flashes, myalgias

describe grade 3 opioid withdrawal

yawning, lacrimation, rhinorrhea, perspiration, mydriasis, anorexia, tremors, hot/cold flashes, myalgias, increased temp, BP, HR, RR/depth

describe the most severe grade of opioid withdrawal

vomiting, diarrhea, hemoconcentration, orgasm

Opioid overdose treatment

Protect airway, assist ventilation, naloxone SC, IV, IM, IN