Management of Morbid ObesityAn Overview

Dr Saurabh KaliaMS,DNB,MCh

Consultant Surgical GastroenterologyNarayana Multispeciality Hospital, Jaipur

WHO factsheet 2015• Worldwide obesity has more than doubled since 1980.• In 2014, more than 1.9 billion adults, 18 years and older, were

overweight. Of these over 600 million were obese.• 39% of adults aged 18 years and over were overweight in 2014,

and 13% were obese.

• Obesity kills more people than underweight.

• 42 million children under the age of 5 were overweight or obese in 2013.

• Obesity is preventable.

Indian scenario• Almost 30-65% of adult urban Indians are either overweight or obese or have abdominal obesity• Rajasthan - 2.6% have BMI>30 ( 20 Lac Obese) CAB Survey 2014

• Obesity related co-morbidities at lower levels of body mass index (BMI) and waist circumference (WC)

Obesity BMI >25 kg/m2, WC cutoff Men: 90 cm, women: 80 cm• Asian Indians have higher percentage body fat, abdominal adiposity at lower or similar BMI levels

Obesity - A Chronic Disease• Impairs bodily function• Characteristic Symptoms and sings• Associated Morbidity and risk of Mortality• Wide range of complications

Physical effects of fat mass

Metabolic and Physiological consequences of fat tissue dysfunction and Insulin resistance

Obesity – A silent killer • Obesity raises the risk of morbidity from

– hypertension ,dyslipidemia, type 2 diabetes mellitus – coronaryheart disease (CHD), stroke, gallbladder disease, – osteoarthritis, – sleep apnea and respiratory problems,– some cancers.

• Obesity is also associated with increased risk of all-cause and CVD mortality.

• The biomedical, psychosocial, and economic consequences of

obesity.

Etiology

• The fundamental cause - energy imbalance between calories consumed and calories expended. – An increased intake of energy- dense foods that are high in fat – an increase in physical inactivity due to the increasingly sedentary nature of work.

• Environmental and societal changes

Pathophysiological mechanisms of Obesity

results in morefavorable impact on obesity-related comorbid conditions

Double Burden of Disease

• In low- and middle-income countries• Problems of infectious disease and under-nutrition, • Obesity and overweight, particularly in urban settings.

• Children. – Exposed to high-fat, high-sugar, high-salt, energy-

dense, micronutrient-poor foods. – In conjunction with lower levels of physical activity,

result in sharp increases in childhood obesity

Healthy Diet• Fruits, vegetables, legumes (e.g. lentils,

beans), nuts and whole grains (e.g. unprocessed maize, millet, oats, wheat, brown rice).

• At least 400 g (5 portions) of fruit and vegetables a day .

• Less than 10% of total energy intake from free sugars which is equivalent to 50g (or around 12 level teaspoons)

• Less than 30% of total energy intake from fats .

– Unsaturated fats are preferable to saturated fats

– Avoid Industrial trans fats found in processed food

• Less than 5 g of salt (equivalent to approximately 1 teaspoon) per day and use of iodized salt.

Comprehensive management of Adult Obesity

• Guidelines, Recommendation, Algorithms– Recognition of individuals to benefit– Presence and Severity of Weight related complications– Assessment of Disease severity– Goals of obesity management– Identification of Therapeutic options

Identifying Individuals

• BMI – Established index• Metabolic Syndrome/

CV risk factors• Waist circumference• Obesity related

complications

Diagnosis of Metabolic syndrome

• The metabolic syndrome is defined as a clustering of cardiovascular risk factors in an individual which predisposes the person to a greater risk of developing T2DM and CVDs

Checklist Obesity Related Complications

• Metabolic Syndrome – Waist circumference, HTN, Triglycerides, HDL-C, FBS

• Pre-diabetes, Type 2 DM• Dyslipidemia• Hypertension• NAFLD• PCOD• OSA• OA• Urinary Stress incontinence• GERD• Disability/Immobility• Psychological disorder• Obesity due to genetic syndrome, Hormonal disease and Drugs

Lifestyle Modification – The core

Elements of Comprehensive Lifestyle Intervention• Reduced calorie diet -

– Set a caloric goal (1,200-1,500 kcal/day for women, 1,500-1,800 kcal/day for men, adjusted for body weight)

– Specify a caloric deficit (500 or 750 kcal/ day)– Restrict/reduce intake of certain food types (e.g., high-carbohydrate, low-fiber, or high-fat

foods) to create energy deficit – Consider patient preferences and health status when identifying a diet

• Increased physical activity – Aerobic activity>150 min/week for weight loss– Resistance training to preserve lean mass – 200-300 min/week aerobic activity to maintain weight loss

• Behavioral intervention – Ideal

• Face-to-face sessions (14 with a trained interventionist over the first 6 months) • Maintain efforts over 1 year• Incorporate strategies such as goal setting and self-monitoring

– Alternatives• Telephone or electronic counseling with a trained interventionist

– Maintenance - Continued contact (once monthly) with a trained interventionist

Stepwise Model for Clinical Management

Dietary Modification• Yo-Yo dieting (cycle of weight gain and loss)- serious health risks

• Low-fat diets that reduce daily energy intake by 2 to 4 MJ – weight loss of 2 to 6 kg– waist-circumference loss of 2 to 5 cm after one year– more effective in maintaining weight loss than low energy diets

• Nutritionally balanced low-energy diets 4 to 5 MJ/day– weight losses of 7 to 13 kilograms and– significant decreases in abdominal fat after six months– half of the weight lost is regained after one to two years

Success of Diet therapy• Successful long-term weight loss is defined as a

– reduction in initial weight of 5 per cent or more – maintenance of this loss for at least one year. – associated with significant clinical benefits – these changes are mostly transient.

• After one year, reduced-energy diets, low-energy diets and very low energy diets used in isolation produce weight losses of about 4, 7 and 4 per cent respectively.

• After three to six years, people prescribed these diets will be, on average, 5, 3 and 6 kilograms lighter respectively

Losing Weight

• Calorie calculation• To lose 1 kg/week eat 1000kcal less every day

Pharmacotherapy• History of being unable to successfully lose and maintain weight• To promote long-term weight maintenance• To ameliorate comorbidities • Amplify adherence to behavior changes• May improve physical functioning and greater physical activity

Drugs – Side effects

Outcomes• Orlistat - 2.59 kg at 6 months and 2.89 kg at 12 months

• Phentermine, diethylpropion -3.0- to 3.6-kg weight loss at 1 year

• Assess Patient's response at 3 months• Effective response (weight loss of >5% at 3 mo) and safe

– medication be continued. • Ineffective response or safety or tolerability issues

– medication be discontinued and – alternative medications or – referral for alternative treatment

Candidates for bariatric surgery• BMI > 40 kg/m2, or BMI > 35 kg/m2 with significant obesity

related comorbidities• Acceptable operative risk• Documented failure of nonsurgical weight loss programs• Psychologically stable, with realistic expectations• Well-informed and motivated patient• Supportive family and social environment• Absence of active alcohol or substance abuse• Absence of uncontrolled psychotic or depressive disorder

Guidelines on Management of Overweight and Obesity in adults

• Identifying patients• Matching treatment with risk profile• Diets for weight loss• Lifestyle intervention counselling• Selecting patients for Bariatric surgery

ACC/AHA Task Force on Practice Guidelines 2013

Bariatric Surgery• Recommended as Adjunct to lifestyle modifications

• Produces greater weight loss and weight loss maintenance

• Results in more favorable impact on obesity-related comorbid conditions

• Weight loss efficacy varies depending on the type of procedure and initial body weight.

Multidisciplinary Team required

Conclusions• Diet, exercise, and behavioral modification -

(BMI) of 25 kg/m 2 or higher.

• Pharmacotherapy for BMI of 27 kg/m 2 or higher with comorbidity or BMI over 30 kg/m2

• Bariatric surgery for BMI of 35 kg/m 2 with

comorbidity or BMI over 40 kg/m 2, should be used as adjuncts to behavioral modification to reduce food intake and increase physical activity when this is possible.

Fountain of Youth

39 year old , Sleeve Gastrectomy in June 2013 – Weight 130 kg, BMI 42kg/m240 year old now , lost about 45 kg , BMI 27.5 kg/m2

New lease of life

40 year old mother of 2, operated in Oct 2013, lost 30 kg over 9 months (from 95 kg to 65 kg ) ,Diabetes resolved

Thank You