What is Obesity?

Obesity means excess accumulation of fat in the body Once it develops it is difficult to cure and usually persists throughout life

Obesity is usually diagnosed on the basis of calculation of

Body mass index Measurement of waist-hip ratio

Classification of Overweight and Obese by Body Mass Index

BMI = Weight (kg) [Height (m)]2 BMI (kg/m2)
Proposed Asia Pacific guidelines

WHO guidelines

Underweight
Normal Overweight

< 18.5
18.5-24.9 25.0-29.9

< 18.5
18.5-22.9 > 23

At risk
Obesity Extremely Obese

30-34.9 (Class I) 35-39.9 (Class II) > 40 (Class III)

23-24.9
25-29.9 (Class I) > 30 (Class II) -

Waist-to-hip ratio
Ratio = WAIST HIPS

Risk increases if waist circumference is >94 cm in men and >80 cm in women

Desired Ratio Women : <0.8 Men : < 1.0

TO FIND RATIO Waist: Measure at narrowest point with stomach relaxed Hips: Measure at fullest point

Co-morbidities risk associated with different levels of BMI and suggested waist circumference in adult Asians

Classification BMI

Risk of co-morbidities Waist circumference < 90 cm (men) < 80 cm (women) > 90 cm (men) > 90 cm (women) Average Increased Moderate Severe Very severe

Underweight < 18.5 Normal range 18.5-22.9 Overweight At risk Obese I Obese II > 23 23-24.9 25-29.9 > 30

Low Average Increased Moderate Severe

Obesity An imbalance in energy intake and energy expenditure

Proteins (20%)

BMR (60-65%)

Fats (25%)

ENERGY INTAKE

ENERGY EXPENDITURE

Thermic effect of food (10%)

Carbohydrates (55%)

Physical activity (25-30%)

Classification of obesity as per fat distribution

Android (or abdominal or central, males)

-Collection

of fat mostly in the abdomen (above the waist)

-apple-shaped -Associated

with insulin resistance and heart disease

Gynoid (below the waist, females)

Collection of fat on hips and buttocks

pear-shaped

-Associated

with mechanical problems

Diseases and conditions for which obesity is a risk factor

Coronary artery disease** Type II Diabetes Mellitus***

Gallbladder disease*** Osteoarthritis**

Infertility*
Venous circulatory disease Increased anaesthetic risk* Low back pain* Polycystic ovary disease* Cancer* (ovarian, breast, endometrial, gallbladder, prostate, colon)

Hypertension**
Dyslipidemia*** Respiratory disease*** Gout** Reflux disease Psychological problems

Prevalence of overweight and obesity in different income groups of Delhi (Nutrition Foundation of India Study)

Prevalence (%) Slums Overweight (BMI > 25) Males Females Obesity (BMI > 30) Males Females ND ND 1 4 ND ND Middle-Class ND ND 32.3 50 49.7 34.9 Total 19.6 44.5 ND ND ND ND

Abdominal obesity Males Females

ND: Not determined

http://www.nutritionfoundationin.org/NEW/OBESITY.HTM

The Five City Study

n=3257; aged 25-64 yrs Cities: Moradabad (n=902), Trivandrum (n=760), Calcutta (n=410), Nagpur (n=405), Bombay (n=780)

Social Class I (n=985)

BMI>27 21.2%

WHR>0.85 96.9%

Sedentary life style 92.2%

II (n=790
III (n=674) IV (n=602)

16.4%
8.9% 3.0%

57.2%
39.3% 11.9%

71.4%
42.3% 14.9%

V (n=206)

3.8%

8.7%

8.7%

Int J Cardiol 1999;69:139-147

Advantages of weight loss

Weight loss of 0.5-9 kg (n=43,457) associated with 53% reduction in cancer-deaths, 44% reduction in diabetes-associated mortality and 20% reduction in total mortality Survival increased 3-4 months for every kilogram of weight loss Reduced hyperlipidemia, hypertension and insulin resistance

Improvement in severity of diseases

Person feels fit and mentally more active

Treatment goals

Prevention of further weight gain

Weight loss to achieve a realistic, target BMI

Long-term maintenance of a lower bodyweight

How much weight loss is significant?

A 5-10% reduction in weight (within 6 months) and

weight maintenance should be stressed in any weight

loss program and contributes significantly to decreased morbidity

Approaches to obesity management

Diet
BMI 23-25
No risk factors DM/CHD/HT/HL BMI 25 30 No risk factors DM/CHD/HT/HL BMI > 30 No risk factors DM/CHD/HT/HL (in severe) (consider in severe) (consider)

Activity

Drugs

VLCD Surgery

Drug therapy
Appetite suppressants

Adrenergic agents (e.g. amphetamine, methamphetamine, phenylpropanol amine, phentermine) Serotonergic agents (e.g. fenfluramine, dexfenfluramine, SSRIs like sertraline, fluoxetine) ephedrine, caffeine

Thermogenic agents

New ones

Sibutramine ; Orlistat

Sibutramine inhibits serotonin and noradrenaline reuptake

Noradrenaline

Serotonin

STORM Study : Effect of sibutramine on weight loss

104 102 100 98 96 94 92 90 0 2 4 6

Bodyweight (kg)

Placebo

Sibutramine 8 10 12 14 16 18 20 22 24 Month Weight maintenance

Lancet 2000; 356:2119-2125

Weight loss

STORM Study: Effect on Waist Circumference and Waist/Hip Ratio

(a) Waist Circumference

Sibutramine
0 -1
1

(b) Waist/Hip Ratio

Sibutramine Placebo
0.8

Placebo

Decrease in waist circumference (cm)

-2 -3 -4 -5 -6 -7 -8 -9 -10
0.5

Change

-4.5

-0.5

-1

-9.2

-1.5

-1.2

STORM Study : Effects on lipids

Triglycerides 5 0 -5 -10 -15 -20 -25

Placebo

VLDL cholesterol 5 0 -5 -10 -15 -20 -25 0 6 12

Placebo

% change

% change

Sibutramine

Sibutramine

12

18

24

18

24

Lancet 2000; 356:2119-2125

STORM Study : Effects on lipids (Contd.)

30 % change 25 20 15 10 5 0 0 6 12 18 Month of assessment Weight loss Weight maintenance
Lancet 2000; 356:2119-2125

HDL cholesterol
Sibutramine

Placebo

24

STORM study: Conclusions

Almost all patients who persist with a weight management program consisting of sibutramine, diet and exercse can achieve at least a 5% weight loss with sibutramine

Over half can lose more than 10% weight within 6 months
Weight loss was sustained in most patients continuing therapy for two years

Sibutramine vs. Dexfenfluramine

Sibutramine 10 mg 0 -0.5 -1 -1.5 -2 -2.5 -3 -3.5 -4 -4.5 -5 Dexfenfluramine 30 mg

Weight loss (kg)

-3.2

-4.5
Int J Obes 1995; 19. Suppl 2: 144

n=226; 12 wks

Adverse effects occurring in >5% of patients treated with Sibutramine compared with placebo
Sibutramine % Incidence (n=2068) 30.3 17.2 13.0 11.5 10.7 7.0 5.9 5.2 5.0 Placebo % Incidence (n=884) 18.6 4.2 3.5 6.0 4.5 3.4 2.8 2.9 2.6
Ann Pharmacother 1999;33:968-978

Adverse Effects
Headache Dry Mouth Anorexia Constipation Insomnia Dizziness Nausea Nervousness Dyspepsia

STORM Study : Withdrawals due to BP increase

Dose of Sibutramine

% patients who
withdrew due to increase in BP

10 mg 15 mg 20 mg

1% 2% 3%
Lancet 2000; 356:2119-2125

Indications & Dosage

Recommended for obese patients with a BMI > 30 kg/m2 or > 27 kg/m2 in the presence of other risk factors (e.g. hypertension, diabetes, dyslipidemia) In Indian patients, sibutramine could be considered in patients with BMI > 25 kg/m2 or those with BMI of 23 kg/m2 with comorbid conditions Recommended starting dose is 10 mg once daily. If there is inadequate weight loss, the dose may be titrated after four weeks to a total of 15 mg once daily. The 5 mg dose should be reserved for patients who do not tolerate the 10 mg dose.