Overweight and Obesity

DR. ABDULAZIZ AL-JOHANI Consultant Family Medicine

Overview
 Definition, Prevalence & Consequences of

Obesity  Healthy Lifestyles  Assessment of Obesity  Treatments for Obesity

Definition
 Obesity is an abnormal accumulation of body fat,

usually 20 percent or more over an individual's ideal body weight.

Definition of Overweight & Obesity

 Using BMI

ITEMS
UNDER WEIGHT

BMI 18.5 18.5 24.9 25.0 29.9 30.0 34.9 35.0 39.9 40

GRADE

NORMAL
OVER WEIGHT

OBESITY OBESITY EXTREME OBESITY

I II III

Calculating BMI
 Calculate Body Mass Index (BMI) =

weight (kg) height squared (meters) Or weight (pounds) x 703 height 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 Adult Obesity, U.S.A.

25 20 ts 15 10 5 0 ex s U te t tes

From CDC website: http://www.cdc.gov/nccdphp/dnpa/obesity/trend/prev_reg.htm

19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01

Factors predispose to obesity

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

Weight Gain: Medications

Disease
Diabetes Depression Seizures Hypertension Hormones

Examples
Insulin, sulfonylureas Tricyclics Valproic acid, Tegretol Clonidine, -blockers, -blockers Progesterone

Weight Gain: How Does It Happen?

 Energy imbalance


calories consumed not equal to calories used

 Over a long period of time  Due to a 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

Evolving Pathology
 More in and less out = weight gain  More out and less in = weight loss  Hypothalamus


control center for hunger and satiety where are the hormones?

 Endocrine disorder


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
 Hormone 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 leptin levels  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

 Major cause of

preventable death  Increase in mortality from all causes  Increase in risk for these cancers
   

Endometrium Breast Prostate Colon

 Increase in risk of:  Hypertension  Dyslipidemia  Diabetes type 2  Coronary artery disease  Stroke  Gallbladder disease  Osteoarthritis  Sleep apnea & respiratory problems

Assessment
 Assess the patient's readiness and willingness to

lose weight :


Unfortunately those who are most concerned about their weights are not necessarily those who are at the highest health risk. Those who are unable or unwilling to embark on a weight reduction program, but they are willing to take steps to avoid further weight gain or perhaps to work on other risk factors such as cigarette smoking, and they should be encouraged to do so. For those not ready to act, the issue should be deferred and brought up at the next visit

Assessment
 Is he overweight? Obese?  What are his key health issues?

Assessment
 Measure 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

Assessment
 Assess for other risk factors


Existing high risk disease:



coronary heart disease; other atherosclerotic diseases; type 2 diabetes; sleep apnea Gynecological problems; osteoarthritis; gallstones; stress incontinence Cigarette smoking; Hypertension; LDL >130; HDL <35; fasting glucose = 110 to 125; family history of premature CHD; men age > 45; women age > 55 Physical inactivity; elevated serum triglycerides

Diseases associated with obesity



Cardiovascular risk factors (3 or more = high risk)



 

Other risk factors



Medications associated with obesity

Treatment Approach
 A multi-faceted

approach is best
  

Diet Physical activity Behavior change

 A Recommendation

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 abnormalities

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 in

order for virtually all 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 Calories Total fat Cholesterol Protein Carbohydrate Calcium Fiber Recommended intake 500 to 1000 kcal/day reduction from usual <30% of total calories <300 mg per day <15% of total calories >55% of total calories 1000 to 1500 mg/day 20 to 30 g/day

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

Weight Maintenance: How Much Should People Eat?

 Varies widely  Some averages, below
Males Age 20-49 Age 50-plus Females Age 20-49 Age 50-plus 2900 calories/day 2500 calories/day 2300 calories/day 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


 Reduces 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

Recommend Physical Activity

 What does it take to burn

1000 calories per week?

Gardening 5 hours

Cycling 22 miles

Running 11 miles

Walking 12 miles Dancing 3 hours

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

Pharmacotherapy for 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

Pharmacotherapy for Weight Loss

Drug Dose Action
Nor epinephrine, dopamine & serotonin reuptake inhibitor

Adverse Effects
Increase in heart rate & blood pressure

Sibutramine 5/10,/15 mg 10 mg po qd to start. (Merida)

May be increased to 15 mg or decreased to 5 mg 120 mg 120 mg po tid before meals

Orlistat (Xenical)

Inhibits pancreatic lipase, decreases fat absorption

Decrease in absorption of fatsoluble vitamins; soft stools and anal leakage

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) - is a pure restrictive surgery since it only involves surgically creating a stomach pouch. VBG uses bands and staples and is the most frequently performed procedure for obesity surgery. Gastric Banding involves the use of a band to create the stomach pouch. Laparoscopic Gastric Banding (Lap-Band), approved by the FDA in June 2001, is a less invasive procedure in which smaller incisions are made to apply the band. The band is inflatable and can be adjusted over time

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) - is the most commonly performed gastric bypass procedure, and the second most frequently performed surgery for obesity after VBG. RGB involves a stomach pouch for food intake restriction. A direct connection, which is Y-shaped, is made from the ileum or jejunum to the stomach pouch for malabsorption. Biliopancreatic Diversion (BPD) - is one of the most complicated obesity surgery, sometimes involving the removal of a portion of the stomach. The remaining section of the stomach is connected to the ileum. BPD successfully promotes weight loss, but this procedure is typically used for persons with severe obesity who have a BMI of 50 or more

Weight Loss Surgery

 Indications
     

100 pounds overweight or more Or, BMI > 40 Or, BMI > 35 and 2 significant comorbidities Age 18 to 60 Documented failure at nonsurgical efforts Psychological stability

Weight Loss Surgery

 Roux-en-Y gastric bypass
 

Limits food intake Alters digestion

Figure from NIDDK website

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 If making favorable progress See more frequently if monitoring medical complications or chronic disease

 Schedule monthly visits for first 3 months

 

 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 Most weight loss doesnt reach individuals ideal (cosmetic) goal

 Focus on medical benefits



Thank You!