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OBESITY.pptx

This document provides an overview of obesity, including its definition, prevalence, assessment, complications, and management. Some key points: - Obesity is defined as abnormal growth of adipose tissue due to enlarged fat cells or increased fat cell number. - Over 1.5 billion adults worldwide are overweight or obese, with the highest rates in the US. Obesity is a risk factor for many chronic diseases. - Assessment methods include BMI, skin fold thickness, and waist circumference. Complications include increased risk of heart disease, diabetes, and some cancers. - Management involves diet, exercise, behavior modification, pharmacotherapy, and sometimes surgery. Treatment aims to reduce calorie intake and increase energy expenditure to promote weight loss

Health & Medicine◦
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OBESITY Dr. RIYAZ Assistant professor Community medicine
0VER VIEW 1. DEFINITION 2. PREVALENCE OF OBESITY 3. PROBLEM STATEMENT 4. EPIDEMIOLOGICAL DETERMINANTS 5. ASSESSMENT OF OBESITY 6. COMPLICATIONS OF OBESITY 7. MANAGEMENT OF OBESITY a) DIET b) PHARMACOTHERAPY c) EXERCISE d) SURGERY
Definition • Obesity may be defined as an abnormal growth of the adipose tissue due to an enlargement of fat cell size {hypertrophic obesity} • or an increase in fat cell number {hyperplastic obesity} • or a combination of both
Distribution of fat
Obesity Prevalence • Over weight and obesity are the fifth leading risk of global death • Obesity has more than double since 1980 • Worldwide 1.5 billion adults are overweight or obese (11% of men/ 14% of women obese) – Overweight/obesity → 2.8 million deaths/yr – U.S. has highest rates in world (36% vs. 32% Mexico, 25% Canada, 4% Switzerland, 5% India)
Problem statement • Key risk factor for natural diseases in other chronic NCDs • Hypertension, hyperlipidaemia, glucose intolerance are first to appear in the transition • CAD and renal failure at a later time (after few decades)
Epidemiological determinants Multiple causation: 1. Age: any age, 1/3rd were so since childhood, obese infant (hyperplastic obesity)difficult to manage with conventional methods 2. Sex: male: 28-35 Female: 45-49 menopausal age/ weight increases with successive pregnancies
Epidemiological determinants 3. Genetic factors: Twin studies showed close correlation between weights even when reared in different environments Also fat distribution has a genetic component 4.Physical inactivity: sedentary lifestyle particularly sedentary occupation and inactive recreation such as watching television, playing video games promote it Energy intake > energy output
Epidemiological determinants 5. socioeconomic status: Inverse relation 6.Eating habbits: e.g., eating in between meals, preference to sweets, refined foods and fats, composition, periodicity. Marketing of energy dense micronutrient poor food
A child whose energy requirement is 2000 kcal/day and who consumes 100 kcal/day extra will gain about 5 kg a year Sugar substitutes: May increase appetite for sweet foods and promote overeating Epidemiological determinants
Epidemiological determinants 7. Psychosocial factors: Overeating may be a symptom of depression, anxiety, frustration, loneliness. • Excessively obese individuals are usually withdrawn self conscious lonely and secret eaters 8. Familial tendency: obese parents tend to have obese children
Epidemiological determinants 9. Endocrine factors: Cushings syndrome, growth hormone deficiency 10. Alcohol: relationship between alcohol and obesity positive for men and negative for women 11. Education: inverse relation 12.Drugs: steroids, Insulin, B adrenergic blockers, contraceptives
INTRA-ABDOMINAL (CENTRAL) FAT ACCUMULATION AND INCREASED RISK • Abdominal obesity is important in the development of insulin resistance and metabolic syndrome (hyperinsulinaemia, Dyslipidaemia, glucose intolerance, and hypertension) that Iink obesity with CHD • Premenopausal women have more lipoprotein lipase (LPL) and higher LPL activity in the gluteal and femoral subcutaneous regions, which contain larger fat cells than those in men, but these differences disappear after menopause.
Assessment of obesity 1. Body weight: a. BMI (Quetelets index): wt(Kg)/ Ht (m2) b. Ponderal index: Ht (cm)/cube root of body weight in kgs c. Brocca index: Ht (cm) – 100
Assessment of obesity d) Lorentzs formula: Ht (cm) - 150 Ht (cm) - 100 = 2 (women) or 4 (men) e) Corpulence index: actual weight desirable weight (should not be < 1.2 for normal)
Assessment of obesity • BMI and Brocas most commonly used • BMI grading: internationally comparable Classification BMI RISK of comorbidities underweight <18.5 Low, but risk of other cinical problems increased Normal 18.5 – 24.99 Average Overweight >_ 25 Pre - obese Obese class I Obese class II Obese class III 25 - 29.9 30 – 34.9 35 - 39.9 >40 Increased Moderate Severe Very severe
Assessment of obesity 2. Skin fold thickness: A large proportion of total body fat is located just under the skin, it is most accessible, rapid and "noninvasive" • Harpenden skin callipers is used for the purpose. • The measurement may be taken at all the four sites - • mid-triceps, biceps, subscapular and suprailiac regions.
Assessment of obesity • The sum of the measurements should be less than 40 mm in boys and 50 mm in girls • Not standardised, difficult to measure in very obese, not repeatable
Assessment of obesity 3. WAIST CIRCUMFERENCE AND WAIST : HIP RATIO (WHR) Waist circumference: mid point between the lower border of the rib cage and the iliac crest. convenient and simple measurement i.e unrelated to height. an approximate index of intra - abdominal fat mass and total body fat. Increased risk of metabolic complications for men with a waist circumference > 102 cm or 40 inches , and women with a waist circumference > 88 cm or 35 inches ). high WHR (> 0.90 in men and > 0.85 in women) indicates abdominal fat accumulation.
COMPLICATIONS OF OBESITY
Complications associated with Obesity Death Cardiac failure Pickwickian syndrome Carcinomas Cholelithiasis Cardiovascular disease DM Venous insufficiency Hyperuricemia Hypertension Hypertriglyceridemia
Management of Obesity
WORK UP Physical exam – Focus on possible complications Investigations: Blood sugar, lipid profile, liver function tests Other tests based on clinical features TSH, Sleep studies Dexamethasone suppression test for Cushing’s syndrome*
Treatment Prevention Diet Increased physical activity Behavior modification Medicines
GUIDE TO TREATMENT OPTIONS
WEIGHT LOSS & WEIGHT MAINTENANCE Integrated weight management
BEHAVIOUR MODIFICATION Self monitoring of weight Stress management Social support
DIET  The primary focus of diet therapy is to reduce overall calorie consumption Very low energy diets (e.g., 400 to 600kcal/d) Low-calorie diets, >800 kcal/d very low fat diets very low carbohydrate diets Guidelines recommend initiating treatment with a calorie deficit of 500– 1000 kcal/d compared with the patient's habitual diet.
Diet The Dietary Reference Intakes for Macronutrients released by the national Institute of nutrition recommends 45–65% of calories from carbohydrates,  20–35% from fat, and 10–35% from protein. daily fiber intake of 38 g (men) and 25 g (women) for persons over 50 years of age and 30 g (men) and 21 g (women)for those under age 50.
Diet Low-carbohydrate, high-protein diets appear to be more effective in lowering BMI; improving coronary heart disease risk factors, including an increase in HDL cholesterol and a decrease in triglyceride levels; controlling satiety in the short term compared with low-fat diets
Diet Occasionally, very low calorie diets (VLCDs) are prescribed as a form of aggressive dietary therapy. The primary purpose of a VLCD is to promote a rapid and significant (13–23 kg) short-term weight loss over a 3- to 6-month period. These propriety formulas typically supply 800 kcal, 50– 80 g protein, and 100% of the recommended daily intake for vitamins and minerals.
EXERCISE Increased energy expenditure is the most obvious mechanism for an effect of exercise Exercise appears to be a valuable means to sustain diet therapy Valuable in the obese individual for its effects on cardiovascular tone and blood pressure
PHARMACOTHERAPY Recommended if BMI >/= 27 with comorbidities or BMI >/= 30 Facts: Drugs alone cause modest weight loss Diet with drugs improves efficacy Effects maintained for duration of treatment only Long term safety data not available
Pharmacotherapy Medications for obesity have traditionally fallen into two major categories: 1. Appetite suppressants (anorexiants) 2. Gastrointestinal fat blockers
Pharmacotherapy Centrally Acting Anorexiant Medication Anorexiants increases satiety and decreases hunger, these agents help patients reduce caloric intake without a sense of deprivation. Targets the ventromedial and lateral hypothalamus Eg PHEN/TPM (Phenteramine and Topiramate)  9.3% and 8.6% weight lost in 2 large trials
Pharmacotherapy Centrally Acting Anorexiant Medication Lorcaserin is a selective 5-HT2C receptor agonist thought to decrease food intake through the propiomelanocortin system of neurons.
Pharmacotherapy Peripherally Acting Medications (Gastrointestinal fat blockers) Orlistat is a synthetic hydrogenated derivative of a naturally occurring lipase inhibitor Lipostatin Acts in the lumen of the stomach and small intestine Blocks the digestion and absorption of ~30% of dietary fat Weight loss of ~9–10%
Pharmacotherapy In development Bupropion and naltrexone Liraglutide
Surgery Indications BMI > 35 with an associated comorbidity or a BMI > 40 (irrespective) Repeated failures of other therapeutic approaches Capability of tolerating surgery
Surgery Weight loss surgeries have traditionally been classified into 3 categories on the basis of anatomic changes: Restrictive Restrictive-malabsorptive Malabsorptive Clinical benefits of bariatric surgery in achieving weight loss and alleviating metabolic comorbidities have been attributed largely to changes in the physiologic responses of gut hormones and in adipose tissue metabolism.
Surgery  Restrictive surgeries limit the amount of food the stomach can hold and slow the rate of gastric emptying.  Malabsorptive surgeries reduce the amount of absorption A.Laparoscopic gastric band (LAGB) B.The Roux-en-Y gastric bypass. C. Biliopancreatic diversion with duodenal switch. D.Biliopancreatic diversion.vertical- banded • gastroplasty E.Biliopancreatic diversion
Surgery These procedures generally produce a 30–35% average total body weight loss that is maintained in nearly 60% of patients at 5 years. Significant improvement in multiple obesity-related comorbid conditions, including type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea, quality of life and long-term cardiovascular events. The most common surgical complications include stomal stenosis or marginal ulcers The restrictive-malabsorptive procedures carry an increased risk for micronutrient deficiencies of vitamin B12, iron, folate, calcium, and vitamin D. Patients with restrictive-malabsorptive procedures require lifelong supplementation with these micronutrients.
Prevention and control • Dietary changes • Increased physical activity • Others: appetite suppressing drugs, gastric bypass, gastroplasty, jaw wiring.. Not effective • Health education is the most common effective measure
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