Menopause and obesity

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MENOPAUSE AND OBESITY Dr. Vandana Bansal MS, D.Phil., DGO, FCGP

Transcript of Menopause and obesity

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MENOPAUSE AND OBESITY

Dr. Vandana BansalMS, D.Phil., DGO, FCGP

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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

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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

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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

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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

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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

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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

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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.

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Prevalence of obesity - India

• Overweight – females – 47.5% males - 32%

• Obese – females – 14% males – 3%

• Abdominal adiposity – females – 35% males – 49%

www.nutritionfoundationofindia.in

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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

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Postmenopausal women: higher prevalence of

obesity compared to premenopausal women

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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)

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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

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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.

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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.

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Mechanisms of Menopause-Related Increases in Adiposity

Menopause

Hormonal changesof the menopausetransition

Estrogen deficiencyAlteredenergy

metabolism

Preferentialabdominal fatAccumulation

Increased fataccumulation

AgeLife-style

Increasedabdominal andintraabdominaladiposity

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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

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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

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Cardiovascular impact of obesity in postmenopausal women

• Blood pressure• Lipids• Metabolic syndrome / diabetes• Inflammation• Coronary artery disease• Stroke• Venous thromboembolism

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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

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Obesity and Diabetes Risk

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Obesity and Hypertension

BMI

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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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BMI

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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.

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Management of obesity in menopausal women

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• 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”.

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Management of obesity in menopausal women

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• 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

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Guide to Selecting Treatment

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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.

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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

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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.

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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

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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

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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

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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

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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

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Yoga and Weight Gain

• Yoga can prevent weight gain and

reduce unwanted fat diposition in middle

age.

• Yoga at least 30 minutes per day.

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Medical Treatment

When do we prescribe medical treatment?

When patients are unable to achieve weight target despite their best effort with diet and exercise

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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

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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

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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

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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

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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.