TITLE:-
BIOPSYCHOSOCIAL FACTORS INFLUENCING OUTCOMES IN PATIENTS WITH ABDOMINAL OBESITY AND MULTISYSTEM COMORBIDITIES
By Dr. VEMULAPALLI HIMAJA (General Medicine PG)
Team Members- Dr. Rakesh Biswas(MD General Medicine), Dr.Vishwak (MD PSYCHIATRY)
INTRODUCTION
Abdominal obesity may be defined as excess deposits of fat in the abdominal region. It is a common health condition seen in South Asians and is positively related to non-communicable diseases (NCDs). It is independent of body mass index and measured by raised waist circumference for men≥90 cm and women≥80 cm1
Waist circumference (WC) and waist-to-hip ratio (WHR) are widely used as indirect measures of abdominal or central adiposity in epidemiological studies. Although the definition of abdominal obesity remains in dispute, the cutoffs for WC (102 cm for men, 88 cm for women) and WHR (0.95 for men, 0.88 for women) were recommended by the American Heart Association and the US Department of Agriculture2
Abdominal obesity was determined as a waist circumference >102 cm in men and >88 cm in women according to the World Health Organization cutoff points and risk of metabolic complications for waist circumference3
.
Several risk factors, such as lifestyle, socio-demography, cultural, and body composition, are associated with Metabolic syndrome4
PROBLEM STATEMENT
Although the biopsychosocial approach has been popularized for many years, it has not been widely used in medical care. Medical staff pay more attention to patients' physical symptoms and less attention to patients' pyschosocial factors5
Abdominal obesity leads to multisystem comorbidities
Biopsychosocial factors leading to accumulation and progression of abdominal obesity with comorbidities are not well known except for few studies
AIM
AIM:
To assess the Biopsychosocial factors influencing outcomes in patients with abdominal obesity and multisystem comorbidities
OBJECTIVES
1) To estimate patients with using anthropometric parameters (waist circumference)
2) To estimate patients with multimorbidities and abdominal obesity
3)To qualtitatively analyse Biopsychosocial factors leading to abdominal obesity and multimorbidities
4)To quantitatively analyse stress and resilence level in these patients
Patients and methods
STUDY DESIGN: Qualitative study design with thematic analysis of factors influencing association of abdominal obesity and comorbidities
STUDY PERIOD: APRIL 2023- MARCH 2025
SAMPLE SIZE: 30 PATIENTS
Methodology
After taking a written consent from the ppatients/relatives, a detailed history is taken and a thorough physical and systemic examinations are performed according to the standard open ended case report formats recorded in standard case reports forms
The case report forms, documents the patients name, age, sex, comorbidities and risk factors
The findings of the clinical exam, abdominal circumference are also recorded in this case report form along with baseline investigations and in patient evaluation of the patient and followup after the discharge.
∙ The study will be approved by the ethics committee of Kamineni Institute of Medical Sciences, Narketpally.
∙ All patient satisfying the inclusion criteria will be enrolled in the study
∙ A written informed consent will be taken from the patients prior to the start of the study.
INCLUSION CRITERIA
Patients above 18 years
Patients with abdominal obesity of waist circumference >102 cm in men and >88 cm in women
Patients with multisystem comorbidities with more than two comorbidities
hypertension
diabetes,
thyroid disorders,
coronary artery disease,
cerebrovascular accidents,
chronic obstructive pulmonary diseases
epilepsy
EXCLUSION CRITERIA
Patients less than 18 years
Patients with less than two comorbidities
Patients without abdominal obesity waist circumference <102 cm in men and <88 cm in women
Patients who doesn’t want to be a part of study
OUTCOMES
MORBIDITY
MORTALITY
Case Proforma
PATIENT DETAILS
Name
Age
Sex
Occupation
Residence
OP/IP number
HISTORY
Biopsychosocial history
Past history:
Personal history:
Bowel and bladder
Diet
Addictions
Allergies
Family history:
General examination
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Edema
Height
Body weight
BMI
ABDOMINAL FAT
Waist-Hip circumference
Investigations (in selected patients)
CBP
CUE
FBS
PPBS
HBA1C
LFT
RFT
THYROID PROFILE
FASTING LIPID PROFILE
ECG
2D ECHO
CHEST X RAY
ULTRASOUND
CT
MRI
PATIENT INFORMATION SHEET
You are invited to participate in a clinical study. Before agreeing to participate in this study it is important that you read and understand why the research is being done and what will happen during it. Please take time to read this information carefully. Take time to ask as many questions as you want. The study personnel will explain any word or information you do not clearly understand. You may to talk to others about the study if you wish.
1.What is the purpose of the study?
TO ASSESS THE BIOPSYCHOSOCIAL FACTORS INFLUENCING OUTCOMES IN PATIENTS WITH VISCERAL FAT AND MULTISYSTEM COMORBIDITIES
2. Why have I been chosen?
You have been approached because you fulfil the entry criteria for the study. These criteria are:
Patients with abdominal obesity of waist circumference >102 cm in men and >88 cm in women
Patients with multisystem comorbidities with more than two comorbidities
hypertension
diabetes,
thyroid disorders,
coronary artery disease,
cerebrovascular accidents,
chronic obstructive pulmonary diseases
epilepsy
3. Do i have to take part?
It is up to you to decide whether or not to take part. If you do, you will be given this information sheet to keep and be asked to sign a consent form. You are still free to withdraw consent from the study at any time and without giving a reason. A decision to withdraw at any time, or a decision not to take part, will not affect the standard of care you receive.
4. What will happen to me if i take part?
The doctors will investigate and any symptoms you may have treat the illness as usual. we will also ask you to answer questions about and also general questions that assess the impact of your illness on your quality of life. We will keep in touch with patients on telephone to check for the symptoms and impact of the illness on your quality of life once in every 3 months for 1year after you get discharged from hospital.
5. Expenses and payments?
Joining the trial will not result in any expenses for you. None of the participants will receive any payment.
6. What do I have to do?
Once you have consented to join the trial, you will be asked to give information to our research team about any symptoms you have, and also answer some questions that assess how your quality of life is affected.
7. What are the other possible disadvantages and risks of taking part?
We are not aware of any disadvantages or risks of joining our study.
8. What are the possible benefits of taking part?
All patients in the study , will benefit from regular follow up for symptoms and quality of life . This may improve the recognition of problems , overall care for all participants and their outcomes.
9. What happens when the research stops?
Patients will leave the trial at the end of the 1year follow up. we plan to publicise the findings of the study widely in the medical literature and local press. depending on the results, we can plan for better care and outcomes of patients.
10. What if there is a problem?
We do not expect any problems related to the study because it is purely an observational study.
11. Will my taking part in the study be kept confidential?
Yes. The information about you will only be known to members of the research team. All information about you will be held using a unique research number so that you cannot be identified in any results, publications or publicity related to the study.
12. Contact details?
Please note the name and phone number of your research doctor. You can contact this person at any time if you have any questions about the study.
NAME:
PHONE NO:
If you have further questions about this study or your participation, or if during your participation you experience a study related injury, please feel free to contact for further information and or for any action to be taken.
13. What if relevant new information becomes available?
Sometimes during the course of a study, new information becomes available. If this happens, the doctor will tell you about it and discuss whether or not you wish to continue in the study. If you wish to withdraw from the study, the study doctor will make arrangements for your continued care. If you decide to continue in the study, you may be asked to sign an updated consent form containing the new information. Both the researchers and an independent committee of experts will be looking out for any new information. If the study is stopped for any reason you will be told why and your continuing care will be arranged.
14. What will happen if I don’t want to carry on with the study?
You are free to withdraw consent from the study without giving a reason at any time. This will not affect the medical care that you receive in any way.
15. What if there is a problem?
Complaints: If you have a concern about any aspect of this study, you should ask to speak with the researchers who will do their best to answer your questions. If you remain unhappy and wish to complain formally, you can do this through complaints procedure. Details can be obtained from the hospital.
Harm: through this if you are harmed, due to participating in the study and or this is due to someone’s negligence then you may have grounds for a legal action for compensation against the trust but you may have to pay your legal costs. the normal complaint service mechanisms will still be available to you.
16. Will my taking part in the study be kept confidential?
Yes. the information about you will only be known to members of the research team. no individuals will be identified in any results, publications or publicity related to the study. we will ask your permission to inform your general practitioner about your participation in the study.
17. What will happen to the results of the research study?
We will inform and publish the findings of the study in the medical literature and widely in the local press. Depending on the results, we may formulate some guidelines for better care and outcomes of patients. You will not be identified in any reports or publications.
18. Who is organising and funding this project?
This project is organised by research team in our medical college and hospital and it is a self funding project.
19. Who has reviewed the study?
Ethics committee of our hospital 🏥
Thank you for taking the time to read this patient information sheet.
రోగి సమాచార పత్రం
Template of this patient information sheet is borrowed from https://www.ncbi.nlm.nih.gov/books/NBK261334/ and modified accordingly
మీరు ఒక క్లినికల్ అధ్యయనంలో పాల్గొనడానికి ఆహ్వానించబడ్డారు. ఈ అధ్యయనంలో పాల్గొనడానికి అంగీకరించడానికి ముందు, మీరు చదివినది అర్థం చేసుకోవడం చాలా ముఖ్యమైనది, పరిశోధన ఎందుకు మరియు దానిలో ఏమి జరుగుతుందో అర్థం చేసుకోండి. ఈ సమాచారాన్ని జాగ్రత్తగా చదవడానికి సమయం తీసుకోండి. మీరు కోరుకున్నట్లుగా చాలా ప్రశ్నలు అడగడానికి సమయం తీసుకోండి. పరిశోధకుడు మీకు స్పష్టంగా అర్థం కాని ఏ పదం లేదా సమాచారాన్ని వివరిస్తారు. మీరు కోరుకుంటే అధ్యయనం గురించి ఇతరులతో మాట్లాడవచ్చు.
అధ్యయనం యొక్క ఉద్దేశ్యం ఏమిటి?
నేను ఎందుకు ఎంపిక చేయబడ్డాను?
మీరు అధ్యయనం కోసం ఉన్న ప్రమాణాలను పూర్తి చేసినందున మీరు ఎంపిక చేయబడ్డారు. ఈ ప్రమాణాలు:
నేను అధ్యయనంలో పాల్గొనవలసిన అవసరం ఉందా?
అధ్యయనంలో పాల్గొనడం లేదా పాల్గొనకూడదని నిర్ణయించడం మీ ఇష్టం. మీరు పాల్గొంటే సమ్మతి పత్రంలో సంతకం చేయమని అడుగుతారు. మీరు ఏ సమయంలోనైనా అధ్యయనం నుండి కారణం ఇవ్వకుండానే బయటకు వెళ్ళవచ్చు. ఏ సమయంలోనైనా అధ్యయనంలో పాల్గొనకూడదనే నిర్ణయం, మీరు స్వీకరించే చికిత్సలో ప్రమాణాన్ని ప్రభావితం చేయదు.
నేను అధ్యయనంలో పాల్గొంటే నాకు ఏమి జరుగుతుంది?
మీరు ఏ విధమైన అనారోగ్యంతో బాధపడుతుంటారు మేము పరిశోధన చేస్తాము. మీ జీవిత నాణ్యతపై మీ అనారోగ్యం యొక్క ప్రభావాన్ని గుర్తించే సాధారణ ప్రశ్నలను కూడా మేము మిమ్మల్ని అడుగుతాము..మీరు హాస్పిటల్ నుండి డిశ్చార్జ్ అయిన తర్వాత ఒక సంవత్సరంలో ప్రతి 3 నెలల్లో ఒకసారి మీ జీవిత నాణ్యతపై అనారోగ్యాల ప్రభావాల కోసం తనిఖీ చేయడానికి టెలిఫోన్లో మేము మీతో మాట్లాడుతాము.
ఖర్చులు మరియు చెల్లింపులు?
ఎటువంటి ఖర్చులు మరియు చెల్లింపులు లేవు.
నేను ఏమి చేయాలి?
అధ్యయనంలో చేరడానికి మీరు ఒకసారి అంగీకరించినట్లయితే, మీరు కలిగి ఉన్న ఏవైనా సమస్యలు గురించి తెలుసుకోవడానికి మరియు మీ జీవిత నాణ్యత ఎలా ఉందో తెలుసుకోవడానికి మేము అడిగిన కొన్ని ప్రశ్నలకు సమాధానం ఇవ్వండి.
అధ్యయనంలో పాల్గొనడం వల్ల కలిగే లోపాలు మరియు ప్రమాదాలు ఏమిటి?
మా అధ్యయనంలో పాల్గొనడం వల్ల కలిగే ఎటువంటి లోపాలు లేదా ప్రమాదాల గురించి మాకు తెలియదు.
అధ్యయనంలో పాల్గొనడం వల్ల కలిగే ప్రయోజనాలు ఏమిటి?
అధ్యయనంలో ఉన్న అన్ని రోగులు, క్రమబద్ధీకరణ మరియు తరచుగా జరిగే సమీక్ష నుండి ప్రయోజనం పొందుతారు. ఇది సమస్యల పునర్నిర్మాణాన్ని మెరుగుపరుస్తుంది,మరియు జీవిత నాణ్యత మెరుగుపడుతుంది
అధ్యయనం ముగిసినప్పుడు ఏమి జరుగుతుంది?
ఒక సంవత్సరం చివరిలో అధ్యయనం ముగుస్తుంది. మెడికల్ లిటరేచర్ మరియు లోకల్ ప్రెస్లో విస్తృతంగా అధ్యయనం యొక్క ఫలితాలు ప్రచురించడానికి మేము ప్రణాళిక సిద్ధం చేస్తున్నాము. ఫలితాలపై ఆధారపడి, మంచి సంరక్షణ మరియు రోగుల జీవిత నాణ్యత కోసం కొన్ని మార్గదర్శకాలను సిఫారసు చేస్తాము.
అధ్యయనంలో నా వ్యక్తిగత వివరాలు రహస్యంగా ఉంటాయా?
అవును. మీ గురించి సమాచారం పరిశోధన బృందంలోని సభ్యులకు మాత్రమే తెలుస్తుంది. మీ గురించిన సమాచారంకు ఒక ప్రత్యేకమైన పరిశోధన సంఖ్య ఉపయోగించపడుతుంది. అందువల్ల మీరు అధ్యయనానికి సంబంధించిన ఏ ఫలితాలు, ప్రచురణలు లేదా పబ్లిసిటీలో గుర్తించబడరు.
సమాచారం కోసం సంప్రదించండి?
మీ పరిశోధన వైద్యుడు యొక్క పేరు మరియు ఫోన్ నంబర్ను దయచేసి గమనించండి మీరు ఈ వ్యక్తిని ఏ సమయంలోనైనా సంప్రదించవచ్చు.
పేరు:
ఫోను నంబరు:
మీరు ఈ అధ్యయనం లేదా ఈ అధ్యయనంలో మీ పాత్ర గురించి ఏవైనా ప్రశ్నలు కలిగి ఉంటే, లేదా మీరు ఒక అధ్యయనం సంబంధిత గాయం అనుభవించినట్లయితే, మరింత సమాచారం కోసం మరియు ఏదైనా చర్య కోసం ఈ వ్యక్తిని ఏ సమయంలోనైనా సంప్రదించవచ్చు.
సంబంధిత కొత్త సమాచారం లభిస్తే?
అధ్యయనం సంబంధిత కొత్త సమాచారం లభిస్తే డాక్టర్ దాని గురించి మీకు చెప్తారు.
మీరు అధ్యయనం నుండి బయటకు వెళ్లాలనుకుంటే, అధ్యయన వైద్యుడు మీ నిరంతర సంరక్షణ మరియు చికిత్స కోసం ఏర్పాట్లు చేస్తాడు. మీరు అధ్యయనంలో కొనసాగాలని నిర్ణయించుకుంటే, క్రొత్త సమాచారాన్ని కొనసాగించే నవీకరించబడిన సమ్మతి పత్రంలో సంతకం చేయమని వైద్యుడు కోరవచ్చు. పరిశోధకులు మరియు నిపుణుల యొక్క స్వతంత్ర కమిటీ ఏదైనా కొత్త సమాచారం కోసం వెతుకుతాయి. ఏ కారణం చేతనైనా అధ్యయనం ఆపివేయబడితే, మీకు సమాచారం ఇవ్వబడుతుంది మరియు మీ నిరంతర సంరక్షణ మరియు చికిత్స అమర్చబడుతుంది.
నేను ఈ అధ్యయనంలో పాల్గొనకూడదనుకుంటే ఏమి జరుగుతుంది?
మీరు ఏ సమయంలోనైనా కారణం ఇవ్వకుండా అధ్యయనం నుండి బయటకు వెళ్ళవచ్చు. ఇది మీరు స్వీకరించే వైద్య సంరక్షణను ఏ విధంగానైనా ప్రభావితం చేయదు.
సమస్య ఉంటే ఏమిటి?
అధ్యయనానికి సంబంధించిన ఏవైనా సమస్యలను మేము ఆశించము, ఎందుకంటే ఇది పూర్తిగా అబ్జర్వేషనల్ అధ్యయనం.
సమస్య ఉంటే:
ఫిర్యాదులు: మీరు ఈ అధ్యయనం యొక్క ఏదైనా కోణాన్ని కలిగి ఉంటే, మీ ప్రశ్నలకు సమాధానమివ్వడానికి పరిశోధకులతో మాట్లాడటానికి మీరు అడగాలి. మీరు ఫిర్యాదు చేయడానికి ఇష్టపడితే, మీరు ఫిర్యాదుల విధానం ద్వారా దీన్ని ఫిర్యాదు చేయవచ్చు. వివరాలు హాస్పిటల్ నుండి పొందవచ్చు.
హాని: ఇది మీకు హాని కలిగించినట్లయితే, అధ్యయనంలో పాల్గొనడానికి చెల్లించాల్సిన అవసరం ఉంది లేదా ఇది కొంతమంది నెగెలిజెన్స్కు చెల్లించాల్సిన అవసరం ఉంది, అప్పుడు మీరు నష్టపరిహారం కోసం చట్టబద్ధమైన చర్య కోసం హక్కు కలిగి ఉండవచ్చు. సాధారణ ఆరోగ్య సేవ ఫిర్యాదు మీకు అందుబాటులో ఉంటాయి.
అధ్యయనంలో నా వ్యక్తిగత వివరాలు రహస్యంగా ఉంటాయా?
అవును. మీ గురించి సమాచారం పరిశోధన బృందంలోని సభ్యులకు మాత్రమే తెలుస్తుంది. అధ్యయనానికి సంబంధించిన ఏ ఫలితాలు, ప్రచురణలు లేదా పబ్లిసిటీలో ఏ వ్యక్తులు గుర్తించబడరు. అధ్యయనంలో మీ భాగస్వామ్యం గురించి మీ వైద్యుడికి సమాచారం ఇవ్వడానికి మేము మీ అనుమతి అడుగుతాము.
అధ్యయనం యొక్క ఫలితాలు ఏమి చేస్తారు?
మేము వైద్య లిటరేచర్ మరియు స్థానిక ప్రెస్లో విస్తృతంగా అధ్యయనం యొక్క ఫలితాలకు ప్రచురిస్తాము. ఫలితాలపై ఆధారపడి, మంచి సంరక్షణ మరియు రోగుల జీవిత నాణ్యత కోసం కొన్ని మార్గదర్శకాలను సిఫారసు చేస్తాము. మీరు ఏ నివేదికలలో లేదా ప్రచురణలలో గుర్తించబడరు.
ఈ ప్రాజెక్టును ఎవరు ఆర్గనైజ్ చేస్తున్నారు మరియు ఫండ్ చేస్తున్నారు?
ఈ ప్రాజెక్ట్ మా మెడికల్ కాలేజీ మరియు హాస్పిటల్లోని పరిశోధన బృందంచే నిర్వహించబడింది మరియు ఇది స్వీయ నిధుల ప్రాజెక్ట్.
అధ్యయనాన్ని ఎవరు సమీక్షించారు?
ఎథీక్స్ కమిటీ
ఈ రోగి సమాచార పత్రం చదవడానికి సమయం కేటాయించినందుకు దన్యవాదములు.
Template of this patient information sheet is borrowed from https://www.ncbi.nlm.nih.gov/books/NBK261334/ and modified accordingly
A Study is conducted by the undersigned in the department of General Medicine
I invite you to participate in the above study. Relevant history needed for study will be collected from the patients. No cost will be incurred by the patients. No monetary gains or financial assistance will be provided to the patients.
The data collected in the study will be used only for research purpose and will be kept strictly confidential. Your participation in this study is voluntary and you have the right to refuse at any point of time during the period of study. Refusal to participate in the study will not affect the treatment or relation with the clinician.
We are thankful for your cooperation.
CONSENT
I/WE, relative of the patient have read and understood the information provided in the patient information sheet and have been informed the purpose of the evaluation in the language I understand.
I am aware of the fact that I may not derive any benefit from the evaluation and that I deserve the right to opt out of the study at any point of time.
I willingly agree to participate in this study
Patients sign/thumb impression: witness sign/thumb impression
Name: name:
Date: date:
Residents sign:
Resident name:
date:
References
1] K.P. Kailash Kumar, J. Jebamalar, A correlation study between types of obesity and hypertension, Int J Med Sci Public Health 7 (12) (2018) 978–982
2] Hsieh SD, Yoshinaga H. Waist/height ratio as a simple and useful predictor of coronary heart disease risk factors in women. Intern Med. 1995; 34: 1147–1152.
3] WHO, “Waist circumference and waist-hip ratio: report of a WHO expert consultation,” WHO, Geneva, Switzerland, 2008.
4) Jayawardena R, Sooriyaarachchi P, Misra A. Abdominal obesity and metabolic syndrome in South Asians: prevention and management. Expert Rev Endocrinol Metab. 2021 Nov;16(6):339-349.
5) Xiao X, Song H, Sang T, Wu Z, Xie Y, Yang Q. Analysis of Real-World Implementation of the Biopsychosocial Approach to Healthcare: Evidence From a Combination of Qualitative and Quantitative Methods. Front Psychiatry. 2021 Oct 26;12:725596. doi: 10.3389/fpsyt.2021.725596: 9-10.
BIOPSYCHOSOCIAL FACTORS INFLUENCING OUTCOMES IN PATIENTS WITH VISCERAL FAT AND MULTISYSTEM COMORBIDITIES
INTRODUCTION
Visceral fat, also known as central obesity or abdominal fat, is a type of body fat that is stored in the abdominal cavity around internal organs such as the liver, pancreas, and intestines. High levels of visceral fat are associated with several health problems, including multisystem comorbidities such as cardiovascular disease, type 2 diabetes, and metabolic syndrome. “3”
The development of visceral fat and multisystem comorbidities is influenced by a complex interplay of biopsychosocial factors. Here are some examples of these factors:
1. Biological factors: Genetic factors, hormonal imbalances, and metabolic disorders can contribute to the accumulation of visceral fat and the development of multisystem comorbidities.
2. Psychological factors: Stress, depression, anxiety, and other psychological factors can lead to overeating and unhealthy eating habits, which can contribute to the development of visceral fat and multisystem comorbidities.
3. Social factors: Social determinants of health, such as (A)socioeconomic status, access to healthy food options, and cultural norms around diet and exercise, can influence the development of visceral fat and multisystem comorbidities.
(B) Lifestyle factors: Sedentary behavior, lack of physical activity, and unhealthy eating habits are all lifestyle factors that can contribute to the development of visceral fat and multisystem comorbidities.
(C)Environmental factors: Exposure to environmental toxins, such as air pollution, may also contribute to the development of visceral fat and multisystem comorbidities.
Visceral fat leads to multisystem comorbidities “3”
Biopsychosocial factors leading to accumulation and progression of visceral fat with comorbidities are not well known except for few studies 1,2,3,4
1. Diagnostic uncertainties:
a. Identifying visceral adiposity: Measuring visceral adiposity can be challenging and there is no universally agreed-upon method for doing so.
b. Overlapping symptoms: Comorbidities such as metabolic syndrome, cardiovascular disease, and chronic kidney disease can have overlapping symptoms, which can make diagnosis difficult.
c. Unrecognized comorbidities: Patients with visceral fat may have comorbidities that have not yet been diagnosed.
2. Therapeutic uncertainties:
a. Optimal treatment strategies: The best therapeutic approach to managing visceral fat and multisystem comorbidities is uncertain, and treatment strategies may need to be individualized.
b. Pharmacotherapy safety and efficacy: There is limited data on the safety and efficacy of pharmacotherapy in patients with visceral fat and multisystem comorbidities.
c. Lifestyle modification effectiveness: While lifestyle modification is often recommended for patients with visceral fat and comorbidities, it is unclear how effective these interventions are in managing these conditions in the long term.
Here is an example of the 45 year old female who came to medicine department
https://shaileshpatil1996.blogspot.com/2023/01/of-45-yr-old-female-school-teacher-by.html?m=1
Case of a 45 yr old female, school teacher by profession.
History:
since menarche, her periods are irregular, happening 10-15 days late than expected.
In 2004, pt had accompanied her mom to a hospital for her uterine tumor Sx (mom's). During that time she was also screened for uterine tumor by Dr. USG was done which revealed gall stone. Sx was done within 2 months. Pt had no complaints or symptoms related to gallstone.
In 2004, while staying in the hospital to get her gallstone operated on, she was diagnosed with hypothyroidism. Since then on medication.
In 2007, she c/o lightheadedness while at school. Later went to a Dr. who found her to be hypertensive. Since then BP under control with medication.
In 2013, she c/o dizziness and malaise. Dr. detected DM. DM is under control with medication.
In 2019, while doing a whole-body checkup, USG was done which detected liver cirrhosis. Pt went to AIG, Dr. after doing tests prescribed atoz multivitamin tab along with another medication which she could not find, hence changed to Heptagon tab. Endoscopy was also done which detected few small polyps in fundus.
In 2021, went to Hyd to get further consultation for liver cirrhosis, USG was done and a rt ovarian cyst was detected. Also, a diagnosis of metabolic syndrome with well compensated cirrhosis of liver was made. Discharged with medications.
She c/o black hairy tongue for the past 1 yr which appears and goes away on its own within few days. She doubts on eating sour items black spots appear more.
Pt claims to be feeling all right with no absolutely complaints. Just came in view of her USG abdomen report. ( outside )
Pt had lost wt from 85(2004) to 66(2022) kgs by controlling her diet.
Denied any history of addiction
Psychosocial history
In 2000, husband had a stroke and she had given birth to a child.
In 2007, hypertension
In 2013, DM
In the family of the patient, she and her elder brother are present.
She was the most affectionate child to her parents.
She got married off very early when she was doing her graduation
She joined as a govt. teacher at the age of 24
She says she had lot of psychological pressure from her mother in law
After she joined the school, she felt guilty that she was unable to give quality time to the family which included her son, daughter and her husband.
Her husband is also working and he is also busy most of the times. So, patient and her husband were unable to communicate properly in her marriage as both of them were working.
She faced a lot of psychological pressure from her mother in law who was of orthodox thinking and she not even allowed the patient to study further after marriage.
In 2017, her father passed away which was a traumatic event for her.
In 2019, diagnosed with cyrhossis of liver.
In 2021, her mother in law passed away and she was in bed for 9 years. her husband was attending her palliative needs. She was guilty and unable to share the palliative responsibilities of her mother in law. Her husband was fragile during all these period.
She is worried about her 13 year old daughter.
She was under severe pressure for her son who wanted to get into medicine.
She was under severe pressure from the local doctor specialist to go for liver transplantation by arranging 30 lakh rupees immediately.
2022, her mother died in October which a huge blow to her. She started sobbing in the session when she referred to her mother’s and father’s death.
sequence:
Hypothyroidism and HTN diagnosed in 2007
Diagnosed diabetes in 2013
Diagnosed ?metabolic syndrome in outside hospital ( doesnt fit in the critera ) with well compensated liver cirrhosis in 2019
ovarian cyst detected in 2021
black spots on tongue appearing and vanishing for the past 1 yr.
FAMILY HISTORY:
Father - HTN,DM
Mom - HTN, DM, Uterus tumor Sx
Mom's cousin sisters- Uterine tumor Sx
Brother - DM
FBS - 122mg/dl
PPBS-148 mg/dl
HbA1C - 7
AIM:
To look at the Biopsychosocial factors influencing outcomes in patients with visceral fat and multisystem comorbidities
OBJECTIVES:
1) To identify patients with visceral fat using anthropometric parameters
2) Identify patients with multimorbidities and visceral fat
3) Identify Biopsychosocial factors leading to visceral fat and progressing to multimorbidities as well as further outcomes
STUDY DESIGN
Qualitative study design with thematic analysis of factors influencing association of visceral fat and comorbidities
Inclusion criteria :
-Patients above 18 years
-Patients with visceral fat
-Patients with multisystem comorbidities with more than two comorbidities like hypertension, diabetes, thyroid disorders, coronary artery disease, cerebrovascular accidents, chronic obstructive pulmonary diseases etc
Exclusion criteria
Patients less than 18 years
Patients without comorbidities
Patients who doesn’t want to be a part of study
SAMPLE SIZE AND DURATION
sample size: 50
Duration:
CASE PROFORMA
Patient details
Age
Sex
Occupation
Residence
History:
Biopsychosocial history
Past history:
Personal history:
Bowel and bladder
Diet
Addictions
Allergies
Family history:
General examination:
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Edema
Visceral fat:
Height
Body weight
BMI
Waist-Hip circumference
Investigations:
CBP
CUE
FBS
PPBS
HBA1C
LFT
RFT
THYROID PROFILE
FASTING LIPID PROFILE
ECG
2D ECHO
CHEST X RAY
ULTRASOUND
CT
MRI
Expected outcome:
The thesis will help people achieve better illness outcomes once the Biopsychosocial root cause is done optimally at the right time and place.
References
1) The clinical application of the biopsychosocial model - PubMed
Kusnanto H, Agustian D, Hilmanto D. Biopsychosocial model of illnesses in primary care: A hermeneutic literature review. J Family Med Prim Care. 2018 May-Jun;7(3):497-500. doi: 10.4103/jfmpc.jfmpc_145_17. PMID: 30112296; PMCID: PMC6069638.
(2) The "Biopsychosocial Model": 40 years of application in Psychiatry - PubMed
Papadimitriou G. The "Biopsychosocial Model": 40 years of application in Psychiatry. Psychiatriki. 2017 Apr-Jun;28(2):107-110. Greek, Modern, English. doi: 10.22365/jpsych.2017.282.107. PMID: 28686557.
Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980 May;137(5):535-44. doi: 10.1176/ajp.137.5.535. PMID: 7369396.
Shuster A, Patlas M, Pinthus JH, Mourtzakis M. The clinical importance of visceral adiposity: a critical review of methods for visceral adipose tissue analysis. Br J Radiol. 2012 Jan;85(1009):1-10. doi: 10.1259/bjr/38447238. Epub 2011 Sep 21. PMID: 21937614; PMCID: PMC3473928.
(4)
Volaco A, Cavalcanti AM, Filho RP, Précoma DB. Socioeconomic Status: The Missing Link Between Obesity and Diabetes Mellitus? Curr Diabetes Rev. 2018;14(4):321-326. doi: 10.2174/1573399813666170621123227. PMID: 28637406.
Questions asked by thesis committee
How do I define trunkal obesity
What outcomes can I see in my thesis in two year study period
Recollection errors while taking Biopsychosocial history and contributing them with the multimorbidities
How can I contribute the abdominal obesity is due to stress eating
Analysis doesn’t come under qualitative study.
(Aim: to analyse Biopsychosocial factors influencing outcomes in patients with multisystem comorbidities)
Corrections by thesis committee
Redo the first slide with title name of the student and guide
Appoint co guide from psychiatry
Need to rewrite the title changing visceral fat to trunkal obesity
Reconstructing the references in Vancouver style
Rephrase the objectives by removing the word “to identify “
Validating
To include USG to measure visceral fat
To restructure consent forms
Version 1
Problem statement: Non-biological factors are overlooked in most of the chronic disease conditions that turned into muti-system
Aim
To look at outcomes through biopsychosocial factors of patients with multisystem comorbidities
Objectives
To look at biopyschosocial factors in patients with multisystem comorbidities
To compare visceral fat with muscle mass and their outcomes
Who is included in my thesis
All patients with more than two systems involved
Who is excluded
Patients without comorbidities
Patients who are not willing to be a part of study
Version 2
Various physiological, psychosocial and clinical factors influence the amount and distribution of the adipose tissue throughout the human body
The progress of biopsychosocial model has been slow, and primary care doctors do not implement biopsychosocial medicine in their practice, while biomedical thinking and approach are still the dominant model
This body composition phenotype is associated with medical disorders such as metabolic syndrome, cardiovascular disease and several malignancies including prostate, breast and colorectal cancers. Quantitative assessment of visceral obesity is important for evaluating the potential risk of development of these pathologies, as well as providing an accurate prognosis
Aim
To look at the Biopsychosocial factors influencing outcomes in patients with visceral fat and multisystem comorbidities
Objectives
To review the implementation in the biopsychosocial model in clinical practice, and its contributions to clinical outcomes in patients with multisystem comorbidities
To clinically assess visceral fat using anthropometric techniques (BMI and WHR)
Version 3
Biopsychosocial factors refer to the interplay between biological, psychological, and social factors that influence a person's health and well-being. These factors are all interconnected and can impact a person's overall health outcomes.
The basic principles of the model included the biological, psychological and social dimensions of the person's life and theperception that the person suffers as a whole and not as isolated organs
The biological factors include genetics, physiology, and medical conditions that can impact a person's health.
Psychological factors include mental health conditions, emotions, attitudes, and beliefs that can influence how a person perceives and copes with their health issues.
Finally, social factors encompass the environment, culture, socio-economic status, family, and social support networks that can impact a person's health outcomes.
By taking into account all these factors, healthcare providers can develop a more global understanding of a patient's health and work towards developing comprehensive treatment plans that address all aspects of their health and well-being.
The progress of biopsychosocial model has been slow, and primary care doctors do not implement biopsychosocial medicine in their practice, while biomedical thinking and approach are still the dominant model.”1”
Medicine is still heavily preoccupied by biomedical thinking, in which disease can be understood independently from the patient suffering from it, and can be explained by abnormal molecular, pathological, and clinical markers observable to the physicians.Biopsychosocial model is neglected or inadequately applied in clinical practice, especially the sociocultural factors.Biological, psychological, social, and spiritual dimensions of illnesses are rarely considered as an integrated whole in most clinical encounters”2”
——-
Abdominal obesity, which is characterised as increased adipose tissue surrounding the intra-abdominal organs, is also referred to as visceral or central obesity. It has been distinctly linked to several pathological conditions including impaired glucose and lipid metabolism, insulin resistance increased predisposition to cancers of the colon ,breast and prostate ,and it is associated with prolonged hospital stays, increased incidence of infections and non-infectious complications, and increased mortality in hospital .Visceral obesity itself is an independent component of metabolic syndrome and the magnitude of obesity directly relates to the prognosis of this condition “3”
Biopsychosocial factors can influence the accumulation of visceral fat in several ways.
the complex interplay between biological, psychological, and social factors can contribute to the accumulation of visceral fat. It is important to address these factors comprehensively to prevent and treat visceral fat accumulation and related health problems such as cardiovascular disease and type 2 diabetes.
———-
Biopsychosocial factors are key determinants of health and illness, and they can influence the development and progression of multisystem comorbidities, which are the presence of multiple chronic health conditions in a single individual. they interact in complex ways to contribute to the development and progression of multisystem comorbidities.
biopsychosocial factors can interact and contribute to the development and progression of multisystem comorbidities. Understanding these factors and their interactions is essential for the prevention, management, and treatment of these conditions. A global approach that addresses biological, psychological, and social factors is often needed to effectively manage multisystem comorbidities
Aim
To look at the Biopsychosocial factors influencing outcomes in patients with visceral fat and multisystem comorbidities
Objectives
To look at Biopsychosocial factors in patients with multisystem comorbidities
To clinically assess visceral fat using anthropometric techniques (BMI and WHR)
PG AND GUIDE CONVERSATIONAL LEARNING
Version 1
05/04/23, 09:44:23] PG STUDENT: Problem statement
Health is Biological
[05/04/23, 09:45:50] PG STUDENT: Aim
To look at outcomes through biopsychosocial factors of patients with multisystem comorbidities
[05/04/23, 09:48:41] PG STUDENT: Objectives
To look at biopyschosocial factors in patients with multisystem comorbidities
To compare visceral fat with muscle mass and their outcomes
[05/04/23, 09:51:04] PG STUDENT: Who is included in my thesis
All patients with more than two systems involved
Who is excluded
Patients without comorbidities
Patients who are not willing to be a part of study
[05/04/23, 09:51:04] PG GUIDE : Briefest problem statement I have come across!
[05/04/23, 09:51:35] PG GUIDE: Please elaborate
[05/04/23, 09:52:10] PG GUIDE: Systematise using standard enumeration
[05/04/23, 09:53:29] PG STUDENT: All patients with more than two systems involved
Sample size 100
[05/04/23, 09:53:56] PG STUDENT: I will just keep it minimum but work on maximum sir
[05/04/23, 09:57:24]PG GUIDE: Don't minimize it to half a phrase like you have.
What you actually meant was "Health is not just biological but also psychosocial but you didn't tell us what that has to do with multimorbidities!
Version 2
[07/04/23, 21:16:43]PG STUDENT: Problem statement
Various physiological, psychosocial and clinical factors influence the amount and distribution of the adipose tissue throughout the human body.
This body composition phenotype is associated with medical disorders such as metabolic syndrome, cardiovascular disease and several malignancies including prostate, breast and colorectal cancers. Quantitative assessment of visceral obesity is important for evaluating the potential risk of development of these pathologies, as well as providing an accurate prognosis.
Aim
To look at the Biopsychosocial factors influencing outcomes in patients with visceral fat and multisystem comorbidities
Objectives
To review the implementation in the biopsychosocial model in clinical practice, and its contributions to clinical outcomes in patients with multisystem comorbidities
To clinically assess visceral fat using anthropometric techniques (BMI and WHR)
PG
[07/04/23, 21:17:10] PG STUDENT: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3473928/
Reference
[07/04/23, 21:19:55] PG STUDENT: Problem statement 2
The progress of biopsychosocial model has been slow, and primary care doctors do not implement biopsychosocial medicine in their practice, while biomedical thinking and approach are still the dominant model
[07/04/23, 21:20:11] PG STUDENT: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6069638/
Reference for problem statement
The progress of biopsychosocial model has been slow, and primary care doctors do not implement biopsychosocial medicine in their practice, while biomedical thinking and approach are still the dominant model
[07/04/23, 22:38:38] PG GUIDE: Cite it in the text where you have quoted it
[07/04/23, 22:39:27] PG STUDENT: Okay sir
[07/04/23, 22:51:33] PG GUIDE: The problem statement presents two separate problems but doesn't join them
It starts with the problem of non implementation of the bps model without explaining to the audience what it is
Next it talks about visceral fat without telling the audience how it's related to the bps model
[07/04/23, 22:57:49] PG GUIDE: Maybe the second paragraph 👇
Various physiological, psychosocial and clinical factors influence the amount and distribution of the adipose tissue throughout the human body.
Can come below the current third with a subsequent para about how various known biopsychosocial factors may influence and how still many factors are unknown (which is the problem)
[07/04/23, 22:59:12] PG GUIDE: This can't be an objective:👇
To review the implementation in the biopsychosocial model in clinical practice, and its contributions to clinical outcomes in patients with multisystem comorbidities
Needs to be rephrased
[07/04/23, 23:01:00]PG STUDENT: Can I rephrase it to
To look at Biopsychosocial factors in patients with multisystem comorbidities
To clinically assess visceral fat using anthropometric techniques (BMI and WHR)
[07/04/23, 23:03:04] PG GUIDE: Objectives:
1) To identify patients with visceral fat using anthropometric parameters
2) Identify patients with multimorbidities and visceral fat
3) identify bps factors leading to visceral fat and progressing to multimorbidities as well as further outcomes
[07/04/23, 23:04:30] PG GUIDE: Elaborate
Inclusion criteria :
All patients with multisystem comorbidities
What Kind of patients
Don't keep your audience guessing
[07/04/23, 23:05:18] PG STUDENT: All patients with visceral fat and multisystem comorbidities sir
[07/04/23, 23:14:14] PG GUIDE: Elaborate
Think of individual patients fitting or not fitting your criteria and you will be able to write that better
[08/04/23, 11:27:24] PG STUDENT: Patients above 18years with visceral fat and multisystem comorbidities involving more than two systems like HTN, DM, THYROID, CAD, CKD, CVA,COPD etc
[08/04/23, 11:27:54] PG STUDENT: Sir is my study method - observational study
[08/04/23, 11:30:58]PG GUIDE: Methods have layers
It's a qualitative study design
So your mentioning quantitative in the problem statement is at odds
Your methods should state:
Qualitative study design with thematic analysis of factors influencing association of visceral fat and comorbidities
[08/04/23, 11:42:30] PG STUDENT: Is this inclusion criteria okay sir
[08/04/23, 11:43:26] PG GUIDE: Always write full forms
[08/04/23, 11:45:30] PG STUDENT: Patients above 18years with visceral fat and multisystem comorbidities involving more than two systems like hypertension, Diabetes,THYROID, coronary artery disease,Chronic renal failure,Cerebrovascular accidents,Chronic obstructive pulmonary disease etc
[08/04/23, 11:52:00] PG GUIDE: Hypertension and diabetes are not organ systems?
[08/04/23, 11:52:54] PG GUIDE: More than two comorbidities
And then mention the morbidities like Thyroid disorder instead of just thyroid etc
[08/04/23, 11:53:46] PG STUDENT: Patients above 18years with visceral fat and multisystem comorbidities involving more than two comorbidities like hypertension, Diabetes,Thyroid disorders,coronary artery disease,Chronic renal failure,Cerebrovascular accidents,Chronic obstructive pulmonary disease etc
[08/04/23, 11:56:25] PG GUIDE: Now break this into 3 points
[08/04/23, 11:58:07] PG STUDENT: -Patients above 18 years
-Patients with visceral fat
-Patients with multisystem comorbidities with more than two comorbidities like hypertension, diabetes, thyroid disorders, coronary artery disease, cerebrovascular accidents, chronic obstructive pulmonary diseases etc
Version 3
[09/04/23, 14:55:13] PG STUDENT: https://himajav.blogspot.com/2023/04/thesis.html
[09/04/23, 15:37:45] PG STUDENT: Sir none of the statements in the introduction are on my own. They are all copy pasted from the internet
[09/04/23, 16:02:36] PG GUIDE: Those copy pasted lines are called quotes.
Please reference each and every sentence that you have quoted
For example see the cited references 1 and 2 mentioned in the text quoted below👇
In recent times, the distinction between organic and functional psychoses has become blurred and these are better described as primary and secondary psychoses, where “secondary” refers to an identifiable pathogenic substrate [1]. Neurodegenerative disorders are known to cause delusions and psychosis by extensive loss of acetylcholine and dopamine releasing projection neurons in the basal forebrain [2].
Check out the 1 and 2 references listed at the bottom of the full text here 👇
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9301093/
[09/04/23, 19:44:35]PG GUIDE: Please add the reference number in the quoted passages and indicate the quoted areas as " "
[09/04/23, 19:45:29]PG GUIDE: Substitute the word holistic with "global"
[09/04/23, 19:48:11] PG GUIDE: Too much of introduction also because a few paragraphs have been pasted twice
[09/04/23, 20:05:55] PG GUIDE: One can only quote 1-2 lines. Not so many!
Also there is too much of content and the end of the Introduction there is no clarity to the problem statement in terms of connection
Final version
[10/04/23, 10:38:30] PG GUIDE: Brief skeleton of your problem statement or need for the study :
Visceral fat leads to multisystem comorbidities aka NCDs (flesh out with insertion of references). Biopsychosocial factors leading to accumulation and progression of visceral fat driven NCDs with comorbidities are not well known except for few studies (insert references)
[10/04/23, 10:39:29] PG GUIDE: Next para you should move to the introductory part of how you will tackle this problem statement by first documenting the spectrum of diagnostic and therapeutic uncertainties in your visceral fat patients with comorbidities presenting to medicine department and how your team resolved them and or were not able to resolve them (outcomes) and in your documentation of the sequence of events surrounding their presentation you will discover the factors influencing the outcomes!
The above is true for all our current projects with different organ systems or multiple systems and needs to be shared with all
[10/04/23, 12:01:32] PG GUIDE: Much better 👏👏
We are nearly there!
But where's your past journey? Version 1 and 2? 🧐
Please reinstate those with the version headers at the bottom asap
[10/04/23, 12:03:24] PG GUIDE: 3 Social
Divide into
a) Economic
b) lifestyle
c) environmental
[10/04/23, 12:05:48] PG GUIDE: This can't be your problem statement alone
It's partly the problem statement
The complete problem statement is :
Visceral fat leads to multisystem comorbidities aka NCDs (flesh out with insertion of references). Biopsychosocial factors leading to accumulation and progression of visceral fat driven NCDs with comorbidities are not well known except for few studies (insert references)
[10/04/23, 12:16:43] PG GUIDE: No your versions are only for the problem statement
[10/04/23, 12:17:12] PG GUIDE: And where is the problem statement in your current version?
[10/04/23, 12:18:34] PG GUIDE: 👆insert this problem statement after your introduction after 3c
[10/04/23, 12:20:04] PG GUIDE: No
That is what you present as your thesis plan now
[10/04/23, 12:20:22] PG GUIDE: Next para you should move to the introductory part of how you will tackle this problem statement by first documenting the spectrum of diagnostic and therapeutic uncertainties in your visceral fat patients with comorbidities presenting to medicine department and how your team resolved them and or were not able to resolve them (outcomes) and in your documentation of the sequence of events surrounding their presentation you will discover the factors influencing the outcomes
[10/04/23, 12:21:06] PG GUIDE: It's an Introduction to the principle behind your methodology
[10/04/23, 12:26:12] PG STUDENT: Visceral fat leading to multisystem comorbidities which is my problem statement is the same as the first para in the introduction sir
[10/04/23, 12:29:07] PG GUIDE: Yes you have a long introduction that buried a few problem statements and you finally need to summarize in brief all those that were buried
Also check reference numbering. One can't have reference 5 as the first in text citation as you have currently done
Project
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