MANAGEMENT OF OBESITYLuthfan Budi Purnomo Division of Endocrinology Internal Medicine DepartmentSchool of Medicine Gadjah Mada UniversityDr Sardjito Hospital Jogjakarta

WHO CLASSIFICATION OF OVERWEIGHT AND THE RISKOF CO-MORBIDITIES ACCORDING BMI VALUESFOR ASIANS (WHO 1999)(Adam, 2004)

ClassificationBMI (kg/m2)Risk of co-morbiditiesUnderweightNormal weightObese Overweight Obese I Obese II

CLASSIFICATION OF OVERWEIGHT AND OBESITY, WAIST CIRCUMFERENCE, AND ASSOCIATED CHRONIC DISEASE RISK Rippe et al., 2001* Adjusted for Asians 90 cm men and 80 cm women (Tan et al., 2004)

Category BMI (kg/m2)Disease risk relative to normal weightand waist circumferenceMen 102 cm >102 cm*Women 88 cm >88 cm* Underweight

Waist circumference WHO 200094 cm () 80 cm () Europe 102 cm () 88 cm () Asia Pacific 90 cm ()80 cm ()

PREVALENCE OF OBESITY67% men57% women 65% 8.4% rural14.9% urban

CONTRIESOVERWEIGHTOBESITYREFERENCIESGlobal (1999-2000)Australia (1999-2000)

USA (99-2000 vs 76-80)Philippine (1998)Peoples Republic of China (1992) Indonesia (1998) (2003-2004)

40%20.2%

17.5%21.91% men19.33% women8.7%

110%

4.7%48.97% men40.65% womenFlorentino, 2002Beard, 2002

Stein & Colditz, 2004

Florentino, 2002

Witjaksono, 2004

The health consequences of overweightand obesity

OBESITY-RELATED DISEASES

DiseasesBMI (kg/m2)RiskReferencesDiabetes mellitus

Hypertension

Cardiovascular mortality26.0 vs 21.0

35.032.035.025.0 to 29.930.0Overweight or obesity

Overweight adolescent8 fold women4 fold men90 fold women11 fold men40 fold men3 fold women6 fold women2 to 3 fold

20 to 30% attributable to excess of body weight>2 fold during adulthoodBeard, 2002

Campbell, 2003

Stein & Colditz, 2004Stein & Colditz, 2004

RELATIVE RISK OF SELECTED OBESITY-RELATEDDISEASES BY SEX, DISEASE, BMI(Oster et al., 2000)

Obesity-related diseasesRelative risk by BMI (kg/m2)

BENEFITS OF LOWERING BODY WEIGHT(Campbell, 2003)

Mortality

Blood pressure

DiabetesLipids20-25% fall in total mortality30-40% fall in diabetes-related mortality40-50% fall in obesity-related cancer deathsFall of 10 mmHg systolic pressureFall of 20 mmHg diastolic pressure30-50% fall in fasting glucose10% decrease in total cholesterol15% decrease in LDL30% decrease in triglycerides 8% increase in HDL

Figure 1. An algorithm for evaluating etiologic and complicating factors of overweight persons. Bray et al., 1976

Obesity Assessment and Treatment Guidelines from NIHI. Assessment A. Measure weight, height and determine BMI B. Measure waist circumference C. Assess co-morbidities D. Assess need for treatment E. Assess readiness for treatmentII. Management A. Set realistic goals 1. Initial weight loss 10% of body weight over 6 months 2. Rate of weight loss 0.5 to 1 kg per week B. Diet 1. Energy intake deficit 500 to 1000 kcal/d 2. Total energy intake never below 800 kcal/d C. Physical activity Gradually work toward >30 min moderate-intensity physical activity on most, and preferably all, days of the week D. Behavior Tools include self-monitoring (record keeping), stress management, stimulus control, problem solving, contingency management, cognitive restructuring and social supportIII. Other options A. Pharmacotherapy (for eligible high-risk patients, if the patient has not lost 0.5 kg per week after 6 months of combined lifestyle therapy B. SurgeryIV. Ongoing assessment and follow-up (Rippe et al.; 2001)

WHEN DO WE START THE MANAGEMENT OF OBESITY?Obese (BMI 30 kg/m2)Overweight (BMI 25.0-29.9 kg/m2) plus 2 risk factors THE GOAL OF OBESITY MANAGEMENTThe initial goal is to lose 5 to 10% body weight over 6 month(Fujioka, 2002)(Fujioka, 2002; Hill & Wyatt, 2002)Weight loss of 5-10% or 2 BMI units may improverisk factors associated with obesity (Kushner & Aronne, 2004)

Pattern A to prevent any further weight gain

Pattern B to decrease body weight 15%

Ideal to normalize risk factors and weight loss to BMI

MANAGEMENT OF OBESITY Non-pharmacologic Treatment Options Diet program Exercise program

Behavioral therapy

Pharmacologic therapy Surgery

Individualized topatients lifestyleand physical needs(Fujioka, 2002)

Dietary ManagementThe goals of dietary approachAchieving a deficit in energy balance of 500-600 kcal/day (results in weight loss 0.5-1.0 kg/week2. Ensuring that obese people following a healthy diet that low in saturated fat and high in complex carbohydrate(Labib, 2003)It is needed long-term changes in food choice, eating behavior, and lifestyle

Dietary Management Total energy intake must be reduced in order for weight loss to occur To prevent weight regain, the lower energy intake must be sustained Conventional low-calorie diets (LCD) Low in energy and fat content High in complex carbohydrate and fiber content Designed for long term maintenance of weight loss Caloric restrictions of 500 to 600 kcal/d lead to weight loss of 0,5 kg per week and 10% decrease in weight by 6 months (Fujioka, 2002)

Dietary Management Very-low-calorie diets (VLCD) Consist of 400-500 kcal/d Designed to produce more rapid weight loss Weight loss 1.5-2 kg per week in women and 2-2.5 kg in men (average 20 kg after 12-16 weeks) c/i moderate to severe liver or renal disease Low-fat diets (LFD)

Dietary Management High-protein diets Higher in total fat, saturated fat, and cholesterol Healthful foods and nutrient sources may be eliminated Metabolic ketosis may suppress appetite AHAs statement: not harmful for most healthy individuals over the short term (Fujioka, 2002)

30 to 45 minutes 3 days per week may expend 150 kcal/d (500 to 600 calories per week)Any form that increases heart rate & energy expenditureWalking 4000 steps per day increasing to 12,000 steps over 6 monthsOr walking 10 minutes on 3 days per week then increase duration, frequency, and intensity (Fujioka, 2002)Exercise

ExerciseRegular exercise is a key strategy for long-termweight control(Miller & Wadden, 2004)The increase of resting metabolic rest may lastno longer than 39 hours

Exercise calculating intensity of exercise E.H.R = (D.I x H.R.R) + R.H.RE.H.R = Exercise heart rateD.I = Desired intensity 40-80% VO2 maxH.R.R.= Heart rate range (maximal H.R. R.H.R)Max H.R. = 200 (0.5 x age)Severe obese, sedentary/not trained D.I. 40-60%, 40 year old, R.H.R 80 x/minE.H.R = ([0.4-0.6] x 100) + 80 = 120 140 x/min

ExerciseOvercoming barriers to exercise adherence

Short-bout exerciseHome-baseLifestyle activityInvolve familyDecrease sedentary behaviorReward system

Behavioral Therapy Designed to change the patients eating and activity habits to reinforce reductions in caloric intake and increase physical activity Self-monitoring of eating habits and physical activity; stress management to diffuse situations; stimulus control to avoid situations that lead to incidental eating; problem solving; cognitive restructuring; social support; relapse prevention after episodes overeating or weight regainConducted in group setting or one-to-one basis To maintenance long-term weight loss may need regular biweekly contact (Fujioka, 2002)

PharmacotherapyBMI 30 kg/m2 or BMI 27 to 29,9 kg/m2 with 1 obesity-related co-morbidity(Fujioka, 2002)

DrugsFDA approved for short-term use Benzphetamine hydrochloride Phendimetrazine tartrate Phentermine Diethylpropion hydrochloride MazinolFDA approved for long-term use Sibutramine hydrochloride (withdrawn) OrlistatMechanism

Stimulates NE releaseStimulates NE releaseStimulates NE releaseStimulates NE releaseBlocks NE reuptake

Blocks NE & 5-HT reuptake

Blocks gastric & pancreatic lipases

Sibutramine (withdrawn)Weight loss of 2,8 to 4,2 kg over 8 to 52 weeksAdverse effects include increased blood pressure,headache, dry mouth, constipationNot recommended if T >145/90 mmHg

Orlistat has similar efficacyMean loss of 3,5 kg over 1 to 2 years durationAdverse effects include abdominal pain, borborygmi,flatus, oily spotting(Labib, 2003; McTigue et al., 2003)Pharmacotherapy

Treatment considerationsPatients who do not lose at least 4 lbs during the first 4 to 8 weeks of therapy should be considered nonresponders to the medication, and consider another antiobesity drugOnce a patient has lost a significant amount of weight, it becomes important to sustain the weight loseEven if the patient does not lose additional weight, it is appropriate to continue the medication as part of a weight-maintenance program (Fujioka, 2002)

SurgeryBMI 40 kg/m2 or BMI 35 to 40 kg/m2 with high-riskco-morbid conditions or significant obesity-relatedphysical conditions

Surgical procedures:Vertical banded gastroplastyGastric bypassMeta-analysis:Reduction in BMI of 16,4 kg/m2 at 12 months andAn overall reduction of 13,3 kg/m2(Fujioka, 2002)

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Xenical Slide Kit August 1998 Section 113Slide 12: Consequences of obesityThe slide illustrates the most common co-morbidities and risk factors associated with obesity. These range from type 2 diabetes, osteoarthritis, cancer of the breast and prostate, major cardiovascular disease, stroke and respiratory disease to gallstones and gout. In short, obesity predisposes patients to a variety of diseases and, accordingly, should be considered by the medical profession as a serious, potentially life-threatening condition rather than an affliction brought on by lack of self-control.

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