Post on 12-May-2015
MENOPAUSE AND OBESITY
Dr. Vandana BansalMS, D.Phil., DGO, FCGP
OBESITY
Obesity is a heterogeneous complex disorder of
multiple etiologies characterized by excessive
accumulation of body fat that threatens or
affects socioeconomic, mental or physical health
Sharma 2007
Obesity: major public health problem
• Universally there are 1 billion overweight adults, among whom 300 million are obese
• Obesity is continuously increasing in the elderly population
• Life expectancy increases– 77 years for men– 82 years for women
• 25% of the population >65 years by 2030• Body fat increases with age, independently of
BMI (sarcopenic obesity)
Han TS et al, BritishMedical Bulletin 2011;1-28
Obesity: Definition
• Obesity is defined in terms of body mass index
• BMI is calculted as weight in kilograms divided by the square of the height in meters (kg/m2)
• WHO Classification of obesity according to BMI• Classification BMI (kg/m2) • Underweight Less than 18.5 • Normal range 18.5- 24.9 • Overweight 25-29.9 • Obese I 30-34.9 • Obese II 35-39.9 • Obese III Greater than or equal to 40.0• Abdominal obesity WC > 88 cm
The apple shape:
also called “android”, “abdominal” or “central” obesity
people with high waist-to-hip ratios are "apples", their body fat is distributed mainly on the upper trunk, the chest and abdomen giving the typical ‘apple shape’
individuals are mostly male
A waist-to-hip ratio >1.0 for men and >0.8 for women indicates an increased risk of cardio-vascular disease and diabetes mellitus
The pear shape:
also called “gynaeoid” or “peripheral” obesity
people with lower waist to hip ratios are "pears“ - their body fat is distributed mainly on the lower trunk, the hips and thighs giving the typical ‘pear shape’.
individuals are mostly female.
associated health risks are minimal if any
Obesity can be classified into two groups on the basis of body fat
distribution and the waist-to-hip circumference ratio.
Classification of Obesity
Classification of obesity Body Mass Index (BMI)
The internationally accepted classification for obesity is the Quetelet's Index, also called the Body Mass Index (BMI)
The BMI is a measure of a person’s weight in relation to height and it is calculated as: weight divided by height squared (kg/m2)
BMI = weight in kilograms = kg/m2
square of height in meters
tion 1
Classification BMI (kg/m2)Risk of co-morbidity
Underweight Less than 18.5
Normal 18.5 - 24.9 Not increased
Overweight or pre-obese 25.0 - 29.9 Increased
Obesity, further classified as: 30.0
Increased as follows:
– Class I 30.0 - 34.9 – Moderate
– Class II 35.0 - 39.9 – Severe
– Class III 40.0 – Very severe
Source: Adapted from WHO 1997
WHO classification of obesity
Prevalence of Obesity
• The prevalence of obesity is increasing world wide and is reaching epidemic proportions
• Majority of adults are becoming increasingly overweight
• Approximately 20% of the adult world population is overweight
• In postmenopausal women this prevalence is growing most rapidly
• Postmenopausal women have an increased tendency for gaining weight
• 44% of postmenopausal women are overweight, among whom 23% are obese.
Prevalence of obesity - India
• Overweight – females – 47.5% males - 32%
• Obese – females – 14% males – 3%
• Abdominal adiposity – females – 35% males – 49%
www.nutritionfoundationofindia.in
Introduction 1
Measurement of obesity
1. Measurements that are simple, cheap and appropriate for routine use include:• Waist circumference• Hip circumference• Waist-to-hip circumference ratio• Body Mass Index (BMI)• Skin fold thickness using callipers (e.g. triceps, scapular)
2. Measurements of body fat that are expensive and require special equipment and highly trained personnel include:• Underwater weighing• Bioelectrical impedance• Computerized topography
Postmenopausal women: higher prevalence of
obesity compared to premenopausal women
Menopausal changes in body composition
• Increase weight• Increase total body fat (%)• Decrease lean body mass• Increase abdominal adiposity
– Increase waist circumference– Increase truncal fat (Dexa Scan)
Cause of obesity in postmenopausalwomen
• Weight gain, during and after the menopause is common
• Contributing factors– Ethnicity– Reduced physical activity– Reduced lean mass– Reduced resting metabolic rate (RMR) and – Treatment with certain drugs e.g. steroids, insulin,
glitazones.– Genetics
Slowing Metabolism
• Decreasing the number of calories a middle age need for energy.
• The muscle mass decrease so less calories needed.
• Muscle need more calorie than fat.
Overeating & Reduced Physical Activities
• Increased appetite• Eating more , cause increasing fat• Less energy needed so less calorie food is
used and it all change to fat around the waist• Hormonal imbalance make you tired• Less tendencies to exercise.
Mechanisms of Menopause-Related Increases in Adiposity
Menopause
Hormonal changesof the menopausetransition
Estrogen deficiencyAlteredenergy
metabolism
Preferentialabdominal fatAccumulation
Increased fataccumulation
AgeLife-style
Increasedabdominal andintraabdominaladiposity
Obese postmenopausal women differ from the general postmenopausal women
1. Hot flushes and menopausal symptoms are more frequent
2. Increased risk of developin coronary heart disease
3. Stroke risk increase linearly with increasing BMI
4. Obesity is associated with increased risk of venous
thromboembolism
5. Obese postmenopausal women are at increased risk of
developing breast cancer (RR : 1.26 – 2.52)
Lambroinoudaki I et al., Maturitas 2010
Adverse effects of obesity in Menopausal Women
• Cardiovascular disease• Diabetes mellitus• Arthritis• Respiratory dysfunction• Urinary incontinence• Cancer (breast, endometrium, colon)• Cognitive dysfunction / dementia• Impaired quality of life
Han TS et al, BritishMedical Bulletin 2011;1-28
Cardiovascular impact of obesity in postmenopausal women
• Blood pressure• Lipids• Metabolic syndrome / diabetes• Inflammation• Coronary artery disease• Stroke• Venous thromboembolism
Obesity is associated with features of the metabolic syndrome (MS)
• Elevated BP (> 135 / 85 mmHg)• increased central adiposity• increased fasting blood glucose (>100mg/dL)• low HDL-cholesterol (<50mg/dL)• or elevated triglyceride levels (>150mg/dL)
MS is an independent risk factor for cardiovascular disease in postmenopausal women
Lin JWet al, J Clin Endocrinol Metab 2010
Obesity and Diabetes Risk
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Obesity and Hypertension
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Relationship between BMI and crude percentage of women reportingmedical problems, surgical procedures, symptoms, and health care utilization.
Brown WJ et al. Int J Obes 1998;22:520-528.
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Obesity and Back Pain
Brown WJ et al. Int J Obes 1998;22:520-528.
Relationship between BMI and crude percentage of women reporting medical problems, surgical procedures, symptoms, and health care utilization.
Management of obesity in menopausal women
25
• Effective management of obesity requires long-term
strategies and an integrated, multi-disciplinary approach
that includes community-based support for behavioural
modification including diet and exercise.
• Research over the last decade indicates that a 5-10%
reduction in body weight is sufficient to significantly
improve medical conditions associated with obesity
• As always, “prevention is better than cure”.
Management of obesity in menopausal women
26
• Prevention is the Key• Team work • Individualized goal of wt loss• Components:
– Education & motivation– Diet modification– Behavioural/lifestyle modifications– Physical activity– Medical treatment– Surgical treatment
Guide to Selecting Treatment
Education & Motivation
• Public support for healthier lifestyles needs to be initiated
• Teach early - why physical activity and healthy eating are so important.
• Provide them with the knowledge and the cognitive skills to manage energy balance in the modern environment.
Dietary Modification Most common and conservative treatment -utilizes a balanced,
low calorie diet
Diet must include more fruit and vegetables, nuts, whole grains and exclude fatty and sugary foods
weight-loss programs recommend diets consisting of 1,200 to 1,500 calories per day, usually in the following proportions: 60 percent carbohydrate 30 percent fat 10 percent protein
The degree of weight loss being dependent on individuals ability to adhere to dietary recommendations
Meal replacements are often more effective than very low calories diets
Select bulky food with low caloric density to produce sense of satiety
Limit salt intake up to 6 g/day• A diet high in natural sources of fiber 25-35 g • Choose foods with lower glycemic index. Low fat diet- Low fat diary products- Vegetables and fruits everyday.
Ensure adequate protein intake toavoid loss of muscle mass
Lean mass
preservation
Body weight
stabilization after
completion of the diet
program
Bopp et al., J. Am.Diet. Assoc. 2008
From Willett WC, Stampfer MJ. Sci Am. 2003;288:64-71.
Balanced Diet Low in Saturated Fat
Red meat and Butter Use Sparingly
Dairy, 1 to 2 Servings
Nuts and Legumes 1 to 3 servings
Fish, poultry and eggs0 to 2 servings
White rice, white bread, potatoes, pasta and sweetsUse Sparingly
Daily exercise and weight control
Plant Oils, At Most Meals
Fruit, 2 to 3 Servings
Whole Grain Foods, At Most Meals
Vegetables, In Abundance
Alcohol in moderationUnless Contraindicated
Alcohol in moderationUnless Contraindicated
Multiple Vitamins, For MostMultiple Vitamins, For Most
Behavioural/Lifestyle modifications
Many eating and exercise habits combine to promote weight gain.
Keeping a food diary that records times, places, activities, and emotions may be linked to periods of overeating or inactivity will reveal areas needing modification
Lifestyle modification is best achieved when the affected
individual is motivated, enthusiastic and supported to achieve set goals
Avoid eating while on their feet, watching TV or playing games. Eat home cooked meals rather than fast foods
Walk rather than use cars, escalators, lifts. Reduce TV hours, and use of energy saving devices
Physical activity
Regular exercise is the single best predictor for achieving long-term weight control
Exercise prevent weight increase after completion of the diet program
Consensus:Minimum of 30 min/dayAt least 2.5 h/week
Physical activity
Independently of weight loss regular exercise
improves:
• Triglycerides
• LDL-c and HDL-c
• Waist girth• Blood pressure • Blood sugar levels in diabetics and • Other obesity-related complications
Yoga and Weight Gain
• Yoga can prevent weight gain and
reduce unwanted fat diposition in middle
age.
• Yoga at least 30 minutes per day.
Medical Treatment
When do we prescribe medical treatment?
When patients are unable to achieve weight target despite their best effort with diet and exercise
Anti-obesity drugs be used only in individuals with a BMI>30kg/m2,
in whom at least 3 months of managed care (supervised diet,
exercise, and behaviour modification) fails to lead to significant
reduction in weight
• Orlistat
• Sibutramine
• Rimonabant
• Metformin ??
Use of these drugs requires strict regular monitoring and must be
discontinued if weight loss is <5% after 12 weeks of use or weight
gain recurs while on the drugs
Gradual reversal of weight loss is known to occur on stopping
pharmacotherapy
Pharmacotherapy
Orlistat:
•The only approved medical treatment of obesity
•Inhibits the absorption of fat from the intestine by inhibiting
pancreatic lipases
•Orlistat prevents the absorption of up to 30% of dietary fat
•Useful for those with a high intake of fat
•3-4% additional weight reduction
Sibutramine:
•Appetite suppression by blocking the re- uptake of
norepinephrine and serotonin in nerve terminals
• Should be avoided in those with hypertension, coronary
artery disease, congestive heart failure
Pharmacotherapy
Rimonabant:
• Endocannabinoid receptor antagonist
• Used as an adjunct to diet and exercise for the
treatment of obese patients (BMI 30 kg/m2)
• Rimonabant is contraindicated in patients on
antidepressants or with history of anxiety or depression
• Nausea, vomiting and mood disorders may limit its use
Pharmacotherapy
Metformin:
• Insulin sensitizer used in the treatment of overweight /
obese diabetics and PCOS women
• In these populations metformin use is associated with a
mild weight decreasing effect
•This is not sufficient to qualify as a primary treatment
for weight loss
• Metformin is not licensed for weight loss
•Should be used as an adjunct in type2 diabetic patients
Pharmacotherapy
Surgical Treatment
Bariatric surgery
Surgery may be a weight-loss option for patients with a BMI of 40 kg/m2 or those with BMI 35kg/m2 & having serious medical complications.
Two accepted surgical procedures : Gastroplasty Gastric bypass
Both reduces the stomach to a small pouch that markedly limits the amount of food consumption
Studies show that there is weight loss of 25 to 30% over the first year post operatively
Longterm monitoring is needed and surgery is not without attendant operative risks.