Obesity

Dr Nadia ShamsAssistant Professor

MedicineRIHS

Approach to overweight and obesity – management of adiposity and adiposopathy

Gonzalez-Campoy JM et al. Endocr Pract. 2013;19 Suppl 3:1-82.

Overweight and obesity should be treated as any other chronic disease

Overview

Definition, Prevalence & Consequences of Obesity

Assessment of Obesity

Treatments for Obesity

Edmonton obesity staging system

AACE guidelines

Definition

“Obesity is an abnormal accumulation of body fat, usually 20 percent or more over an individual's ideal

body weight.”

BMI

(Adapted from WHO, 1995, WHO, 2000 and WHO 2004)

BMI

UNDER WEIGHT ≤ 18.5

NORMAL 18.5 – 24.9

OVER WEIGHT 25.0 – 29.9

OBESITY GRADE I 30.0 – 34.9

OBESITY GRADE II 35.0 – 39.9

EXTREME OBESITYGRADE III

≥ 40

BMI Cut off for AsiansBMI cut-off Weight status Comments

<18.5 Underweight

Being underweight also puts you at risk for developing many health problems. Discuss with your healthcare provider about how to reach a healthy weight.

18.5 - 23.9 Healthy weight range

Your weight is within normal range. You can continue to keep a healthy weight through physical activity and healthy eating. Keep up with the good work!

24 - 26.9 Overweight

Being overweight can put you at risk for developing many chronic diseases. Discuss with your healthcare professional on how to achieve a healthy weight.

>27 Obese

Obesity increases risks for developing many chronic diseases such as heart disease and diabetes, and decreases overall quality of life. Discuss with your healthcare provider about how to achieve a healthy weight!

Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004; 363:157-63

Target Waist Circumference for Asians and Asian Americans

Men Women

Equals or less than 90cm (35.5 in)

Equals or less than 80cm (31.5 in)

Calculating BMI

• Calculate Body Mass Index (BMI)

weight (kg)height squared (meters)

Or…

weight (pounds) x 703height squared (inches)

Prevalence of Obesity

• Childhood and adolescent obesity increased from 5% to 16% in the last 20 years

• Adulthood obesity increased from 12% to 21% in 10 years.

• 16 million US adults with BMI over 35 & 60 million US obese adults (BMI > 30)

Prevalence of Obesity in Pakistan

Prevalence of obesity (BMl>25) in 25-44 year olds in rural areas was 9% for men and 14% for women

in urban areas, 22% and 37% for men and women, respectively.

For 45-64 year olds, prevalence was 11% for men and 19% for women in rural areas and 23% and 40% in urban areas for men and women, respectively.

(DJ Nanan. The Obesity Pandemic - Implications for Pakistan. 2002: JPMA)

Factors predisposing to obesity

• Genetic – familial tendency.• Gender – women more susceptible .• Activity – lack of physical activity.• Psychogenic – depression .• Social class – poorer classes. • Alcohol – problem drinking. • Smoking – cessation smoking. • Prescribed drugs – tricyclic derivatives.

Medications leading to weight gain

Disease Examples

Diabetes Insulin, sulfonylureas

Depression Tricyclics

Seizures Valproic acid, Tegretol

Hypertension Clonidine, α-blockers, β-blockers

Hormones Progesterone

Weight Gain: How Does It Happen?

•Calories consumed are not equal to calories used

•Occurs over a long period of time due to combination of several factors

• Individual behaviors• Social interactions• Environmental factors• Genetics

Weight Gain: Energy In

3500 calories = 1 pound

• 100 calories extra per day• = 36,500 extra per year• = 10.4 lbs weight gain

Question: How much is 100 calories?Answer: Not very much!

• 1 glass skim milk, or• 1 banana, or• 1 slice cheese, or• 1 tablespoon butter

Leptin• Protein hormone secreted by adipocytes• Levels correlate with lipid content of cells• Leptin acts on the hypothalamus to reduce

hunger and to stimulate energy expenditure

Ghrelin

• It is secreted in the stomach• Acts on the hypothalamus to stimulate appetite• Levels peak just before meals and drop afterward

Bad News for Dieters

• Leptin• Dieting decreases the leptin levels• Thus reducing metabolism, stimulating appetite

• Ghrelin• Levels in dieters are higher after weight loss• The body steps up ghrelin production in

response to weight loss• The higher the weight loss, the higher the

ghrelin levels

Health Consequences of Obesity . . .

Health Consequences of Obesity• Major cause of preventable

death

• Increase in mortality from all causes

• Increased risk for these cancers• Endometrial carcinoma• CA Breast• CA Prostate• CA Colon

• Increased risk of:

• Hypertension• Dyslipidemia• Diabetes Mellitus type 2• Coronary artery disease• CVA• Gallbladder disease• Osteoarthritis• Sleep apnea & respiratory

problems

Assessment

• Is he/ she overweight or 0bese?• What are the key health issues?

Assessment

• Measure the Body Mass Index- BMI

• Measure waist circumference• “Apple shape” body is higher risk for DM, CVD, HTN

• Waist larger than 40 inches for men • Waist larger than 35 inches for women

Assess for other risk factors

• Pre-existing high risk disease:• coronary heart disease; Type 2 diabetes; • sleep apnea

• Diseases associated with obesity• Gynecological problems; osteoarthritis; gallstones; stress

incontinence

• Cardiovascular risk factors (3 or more = high risk)• Cigarette smoking; Hypertension; LDL >130; HDL <35; fasting

glucose = 110 to 125; family history of premature CHD; men age > 45; women age > 55

• Presence of other risk factors• Physical inactivity; elevated serum triglycerides

• Medications associated with obesity

Assess for other risk factors

Cardiovascular risk factors (3 or more = high risk)________________________________________

•Cigarette smoking•Hypertension; LDL >130•HDL <35•fasting glucose = 110 to 125•family history of premature CHD•men age > 45•women age > 55

Treatment Approach

• A multi-faceted approach is best

• Diet• Physical activity• Behavior change

Treatment Approach

• Initial goal: 10% weight loss• Significantly decreases risk factors

• Rate of weight loss• 1 to 2 pounds per week• Reduction of caloric intake 500-1000 per day

• Slow weight loss is more stable• Rapid weight loss is almost always followed by weight

gain• Rapid weight loss increases risk for gallstones &

electrolyte imbalances

Treatment Approach• Aim for 4 - 6 months of weight loss effort

• Most people will lose 20 to 25 pounds

• After 6 months, weight loss is more difficult• Ghrelin & Leptin are at work!• Changes in resting metabolic rate• Energy requirements decrease as weight decreases• Diet adherence wavers

• Set goals for weight maintenance for next 6 months, then reassess.

Dietary Therapy• Weight reduction with dietary treatment is

recommended for virtuallyall patients with a BMI 25-30 who have comorbidities and for all patients over BMI 30.

• Strategies of dietary therapy include teaching about calorie content of different foods, food composition (fats, carbohydrates, and proteins), reading nutrition labels, types of foods to buy, and how to prepare foods.

Low-Calorie Step I Diet

• 1000 to 1200 kcal/day for women

• 1200 to 1600 kcal/day for men

• Adjust for current weight & activity

• Too hungry? • increase kcal by 100 - 200/day

• Not losing? • decrease kcal by 100 - 200/day

How Much is 1200 Calories?

• Could you stick to 1200 per day?

1 Big Mac (580)1 SMALL Fries (210)1 SMALL shake (430)

Low-Calorie Step I Diet

Nutrient Recommended intake

Calories 500 to 1000 kcal/day reduction from usual

Total fat <30% of total calories

Cholesterol <300 mg per day

Protein <15% of total calories

Carbohydrate >55% of total calories

Sodium Chloride <2.4 g sodium, or <6 g sodium chloride

Calcium 1000 to 1500 mg/day

Fiber 20 to 30 g/day

Weight Maintenance: How Much Should People Eat?

• Varies widely• Some averages, below

Males Age 20-49 2900 calories/day

Age 50-plus 2500 calories/day

Females Age 20-49 2300 calories/day

Age 50-plus 1900 calories/day

Physical Activity

• Physical activity should be an integral part of weight loss

• Physical activity alone is less successful than a combined diet & exercise program

• Increased activity alone does not decrease weight• Sustained activity does prevent weight regain

• risk for heart disease & diabetes

Physical Activity

• Start slowly• Many obese people live sedentary lives• Avoid injury• Early changes can be activities of daily living

• Increase intensity & duration gradually

• Long-term goal• 30 to 45 minutes or more of physical activity• 5 or more days per week• Burn 1000+ calories per week

Recommended Physical Activity

• What does it take to burn

1000 calories per week?

Running 11 miles

Walking 12 miles

Dancing 3 hours

Gardening 5 hours

Cycling 22 miles

Behavioral Strategies

• Keep a journal of diet & activity• Very powerful intervention!

• Set specific goals re: behaviors• Eating• Activity• Related behaviors

• Track improvement • Weigh & measure on a regular basis

Cognitive Strategies

• Focus on the goals• Plan meals & activity• Develop reminder systems • Anticipate temptations & plan resistance• Reward yourself• Limit quantities, but do not deprive yourself• Have confidence in your ability to succeed• Do positive self-talk

Pharmacotherapy for Weight Loss

_______________________


• Adjunct to diet & physical activity

• BMI ≥ 30 Or, BMI ≥ 27 with other risk factors

• Should not be used for cosmetic weight loss• Only for risk reduction

• Use only when 6-month trial of diet & physical activity fails to achieve weight loss


• These drugs are only modestly effective• 2 to 10 kilogram loss• Most occurs in the first 6 months

• If patient does not lose 2 kilograms in the first 4 weeks, success is unlikely

• If the first 6 months is successful, continue medication as long as…

• It is effective in maintaining weight, and• Adverse effects are not serious

Xenical (orlistat) product information. South San Francisco, CA: Genentech USA, Inc; December 2013. Belviq (lorcaserin) product information. Woodcliff Lake, NJ: Eisai Inc; August 2012.

Qsymia (phentermine and topiramate extended-release) product information. Mountain View, CA: Vivus, Inc; September 20139

Weight Loss Surgery• 47,000 in 2001; 98,000 in 2003

• Types of Obesity Surgery:

• 1. Restrictive Surgery - uses bands or staples to create food intake restriction:

• Vertical Banded Gastroplasty (VBG) • Gastric Banding • Laparoscopic Gastric Banding (Lap-Band),

Weight Loss Surgery• 2. Combined Restrictive and Malabsorptive Surgery

-is a combination of restrictive surgery (stomach pouch) with bypass (malabsorptive surgery), in which the stomach is connected to the jejunum or ileum of the small intestine, bypassing the duodenum.

• Roux-en-Y Gastric Bypass (RGB)• Biliopancreatic Diversion (BPD) -

Weight Loss Surgery

Indications

100 pounds overweight or moreOr, BMI > 40Or, BMI > 35 and 2 significant comorbiditiesAge 18 to 60Documented failure at nonsurgical effortsPsychological stability

Weight Loss Surgery

• Roux-en-Y gastric bypass

• Limits food intake• Alters digestion

Weight Loss Surgery

• Complications of surgery• Mortality

• <1% mortality in healthy young adults BMI < 50• 2-4% mortality in patients with disease and BMI > 60

• Operative complications• < 10%

• Late complications are uncommon• Incisional hernias• Gallstones• Vitamin B12 & iron deficiency

• Weight loss failure• Neurologic symptoms in unusual cases

Weight Loss Surgery Outcomes

• Durable weight loss• One study followed pts for 14 years

• Average excess weight loss = 61.2%• 77% with diabetes no longer require

meds• From Wald meta-analysis in JAMA 2004)

Followup

• Schedule a return visit in 2 to 4 weeks after starting weight loss plan• Monitor treatment effectiveness & side effects

• Schedule monthly visits for first 3 months• If making favorable progress• See more frequently if monitoring medical

complications or chronic disease

• Reduce frequency of visits after 6 months

Followup

• Monitor weight, BP, pulse at each visit

• Monitor waist size intermittently

• Share progress with patient; praise efforts

• Share lab results with patient• Emphasize findings associated with weight reduction

• Focus on medical benefits• Most weight loss doesn’t reach individual’s ‘ideal’ (cosmetic)

goal

EDMONTON OBESITY STAGING SYSTEM

Anthropometric measures alone are not a good reflection of the severity or extent of obesity-related comorbidities.

Sharma and Kushner have suggested a clinical staging system to complement the BMI when describing the severity of obesity.

(http://www.drsharma.ca/clinical-assessment-edmonton-obesity-staging-system)

The Edmonton Obesity Staging System is

used together with BMI class for management of obesity.

____________________________________

Edmonton Obesity Staging System (EOSS)

Stage 0

(Sharma AM & Kushner RF, Int J Obes 2009)

Stage 1

Stage 2

Stage 3

Stage 4

Med

ical

Men

tal

Func

tiona

l

abse

nt

abse

nt

abse

nt

pre-

clini

cal

risk

fact

ors

mild

mild

co-morbidity

moderate

moderateend-organ

damage

severesevere

end-stage

end-stage

end-stage

Obesity

STAGE - 0

Patient has no apparent obesity-related risk factors (e.g., blood pressure, serum lipids, fasting glucose, etc. within normal range)

no physical symptoms, no psychopathology, no functional limitations or impairment of well-being.


STAGE - 1

Patient has one or more obesity-related sub-clinical risk factors (e.g., elevated blood pressure, impaired fasting glucose, elevated liver enzymes, etc.)

mild physical symptoms (e.g., dyspnea on moderate exertion, occasional aches and pains, fatigue, etc.)

mild psychopathology, mild functional limitations and/or mild impairment of well-being.


STAGE - 2

Patient has one or more established obesity-related chronic diseases requiring medical treatment (e.g., hypertension, type 2 diabetes, sleep apnea, osteoarthritis, reflux disease, polycystic ovary syndrome, anxiety disorder, etc.)

moderate functional limitations and/or moderate impairment of well-being.


STAGE - 3

Patient has clinically significant end-organ damage.

such as myocardial infarction, heart failure, diabetic complications, incapacitating osteoarthritis, significant psychopathology, significant functional limitations and/or significant impairment of well-being.


STAGE - 4

Patient has severe (potentially end-stage) disabilities from obesity-related chronic diseases, severe disabling psychopathology, severe functional limitations and/or severe impairment of well-being .


EOSS Predicts Mortality in NHANES III

(Padwal R, Sharma AM et al. CMAJ 2011

EOSS Predicts Mortality at Every Level of BMINHANES III

(Padwal R, Sharma AM et al. CMAJ 2011)

Overweight

Association Between EOSS and Mortal ity Risk in Aerobics Center Longitudinal Study (n = 29 533)

Kuk JL, et al. Appl. Physiol. Nutr. Metab. 2011;36: 570

EOSS Case 1

24 year-old physically active female, BMI of 32 Kg/m2

no demonstrable risk factors, no functional limitations, or mental health issues

Class I, Stage 0 Obesity

- Focus on prevention of further weight gain- Health benefits of more aggressive obesity

treatment likely marginal

Sharma AM & Kushner RF, Int J Obes 2009

EOSS Case 2

32 year-old male BMI of 36 Kg/m2

hypertension, sleep apnea, depression

Class 2, Stage 2 Obesity

- Clear benefits of obesity treatment


EOSS Case 3

63 year-old male BMI of 54 Kg/m2

disabling osteoarthritis (wheel chair)severe hypoventilation, fibromyalgia,

generalized anxiety disorder

Class 3, Stage 4 Obesity

Aggressive obesity treatment unless deemed palliative


Thank You!

20141990

Obesity

Health & Medicine

Transcript of Obesity